Care Co-ordinator

The Care Co-ordinator (Care Homes) will work closely with the Clinical Team to support patient care and the delivery of timely, appropriate and well-co-ordinated enhanced care services to care home residents. You will also maintain an awareness of the wider patient cohorts supported by the Enhanced Care Team, contributing to effective multidisciplinary working, service continuity, and the sharing of best practice across the team.

You will proactively manage a caseload of patients with complex care needs, ensuring coordinated, person-centred support and timely review of changing health and wellbeing needs.

You will act as a key link between the Practice and our local care homes, coordinating care plans, medication and health reviews, supporting weekly care home ward rounds, registration of new residents and supporting clinicians. You will build relationships and work closely with patients, carers, care home staff, GPs, community services, and partner organisations. Ultimately helping us to deliver high-quality, integrated care that improves patient outcomes and experience.

You will support the development and review of personalised care plans, facilitating access to health and care services, promoting effective communication across healthcare providers.

and manage a caseload of identified patients, making sure that appropriate

support is made available to them, and ensuring that their changing needs are

addressed

Bring

together all the information about a persons identified care and support needs

and explore options to meet these within a single personalised care and support

plan

Help

create single personalised care and support plans, in line with best practice

Assist

and direct patients in accessing the appropriate service or healthcare

professional in a courteous, efficient and effective way

Facilitate

effective communication between patients, members of the primary health care

team, secondary care and other associated healthcare agencies

Support

a formalised process of delivering healthcare reviews to patients

the Clinical Directors and team to deliver the Directed Enhanced Services

specifications for individual services

Co-ordinate

the work of healthcare professional and non-clinical staff including volunteers

and keep an up-to-date database of contacts

and develop relationships with partner organisations, such as community

services, volunteer groups, community learning disability teams, care homes and

keep a comprehensive and up to date database of contacts

Provide

a link between Vine Medical Group and Homewell Practice

advice and information ensuring health and care planning is timely, efficient

and patient-centred

Ensure

that all relevant and useful information is available to patients/clinicians

and is up to date

Support

teams with quality improvement projects and achieving KPIs (QOF and IIF)

Monitor

and cleanse existing data. Ensure data

is recorded and coded accurately and aligned with the PCN

Understand

and provide support for digital initiatives

Attend

regular / monthly meetings to discuss good practice and share information

Keep

records of your work and adhere to confidentiality, information sharing

protocols and provide monitoring information as required

Undertake

regular training to extend and update own knowledge of health and wellbeing

issues

Alert

Team Lead or Senior Management of any issues that may impact patient safety or

service quality

Be

familiar with patient safety policy and reporting (e.g. LFPSE and/or other

appropriate systems) and awareness of the process and key stakeholders for

safeguarding referrals

Maintain

accurate patient / clinical records in conjunction with Practice policies and

current legislation

Ensure

adherence to confidentiality, data protection, and information governance

Work

safely at all times in accordance with legislative requirements and Practice

local care homes to support GP-led ward rounds to ensure support and access and

coordinate clinical unput where required. Regular travel across the locality is

an essential requirement of the role

Register

new care home patients and manage proxy access, liaising with the Admin team

and care home managers as required

Co-ordinate

regular Multi-disciplinary Team meetings. Take notes and record actions at these

meetings

Manage

the Practices care home email inboxes and ensure that all emails and documents

are dealt with or distributed to the appropriate clinician

Keep

up to date contact information and processes for all care homes

Ensure

that all relevant and useful information is available to the care homes and is

up to date

Develop

relationships with external third parties that help support care homes and

their residents

Ensure

that all relevant information or changes from external stakeholders, such as

Care Home Managers, CCG, NHS England is shared with the Care Home Team

Maintain

patient appointment lists for ward rounds

Vine Medical Group is one of the largest practices in the

locality. We care for around 25,500

patients across the whole of the Waterlooville area and its surrounding

villages. We are one of two practices in Strawberry Health Primary Care Network with shared responsibilities for approximately 41,000 patients.This larger size means more

diverse learning and development opportunities are possible to aid with longer

term career development goals. We are a family-friendly practice and try to

accommodate working patterns to suit as far as we can.

We operate across four locations; the Forest End, Waterlooville Health

Centre, Aintree Drive and Stakes Lodge sites.

We employ a multi-skilled team including GPs, Practice Nurses, Advanced Nurse

Practitioners, Healthcare Assistants, Paramedics, Pharmacists and skilled

administrative teams who support the smooth running of the Practice.

Our Enhanced Care Team includes Social Prescribers, Care

Co-ordinators, Wellbeing Advisors and Mental Health Practitioners. The team

proactively supports our patients health and wellbeing providing a

personalised care approach.

We are rated Good by the CQC.

Qualifications

Essential: - GCSE in English and Maths at Grade C/4 or equivalent

Knowledge & Skills

Experience