Care Coordinator

Utilise both internal and external population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.

To undertake Personalised Care Training commensurate with the role.

Support patients to utilise decision aids in preparation for a shared decision-making conversation.

Holistically bring together all of a persons identified care and support needs and explore options to meet these within a single personalised care and support plan (PCSP).

Help patients to manage their needs through answering queries, making and managing appointments and ensuring that people have good quality written or verbal information to help them make choices about their care.

Assist patients to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level.

Co-ordinate the delivery of the Multi-Disciplinary Team Meetings within the Practice, Care Homes and external providers.

Build and maintain effective professional relationships with the MDT and create a network of contacts to assist the MDT in providing the most effective package of patient care.

Schedule and organise MDT meetings, liaising with key members of the team. Manage all administrative duties to include preparation and distribution of agenda items and the taking and distributing of meeting minutes and action plans.

The following are the core responsibilities of the

role. There may be on occasion, a requirement to carry out other tasks; this

will be dependent upon factors such as workload and staffing levels:

Utilise both internal and external population

health intelligence to proactively identify and work with a cohort of patients

to deliver personalised care.

with the role.

Support patients to utilise decision aids in

preparation for a shared decision-making conversation.

Holistically bring together all of a persons

identified care and support needs and explore options to meet these within a

single personalised care and support plan (PCSP).

Help patients to manage their needs through

answering queries, making and managing appointments and ensuring that people

have good quality written or verbal information to help them make choices about

their care.

Assist patients to access self-management education

courses, peer support or interventions that support them in their health and

wellbeing and increase their activation level.

Co-ordinate the delivery of the Multi-Disciplinary

Team Meetings within the Practice, Care Homes and external providers.

Work with the GPs and other primary care

professionals to identify and manage a caseload of patients and where

required/appropriate, refer patients onto to other health professionals.

Build and maintain effective professional

relationships with the MDT and create a network of contacts to assist the MDT

in providing the most effective package of patient care.

Schedule and organise MDT meetings, liaising with

key members of the team. Manage all

administrative duties to include preparation and distribution of agenda items

and the taking and distributing of meeting minutes and action plans.

Take responsibility for co-ordinating the actions

arising from the meetings ensuring that this is carried out in a timely, effective

and coherent manner.

Ensure that all patients Care Plans, diagnostics

results and associated correspondence are available to the MDT, liaising with

all agencies as appropriate, accessing IT systems to ensuring relevant

information is available.

Act as a contact to assist with case management of

patients at risk of admission, identifying sources of support in liaison with

the primary care team.

Act as a conduit between the Practice Clinical Team

and the external Care Homes, providing first line support and guidance and

ensuring an effective and efficient package of support is provided to our Care

Homes patients. This includes ringing

the care homes on a weekly basis.

Assist in the identification of housebound

patients, work with the primary care team and social prescriber to ensure that

the package of care provided to this cohort suits the individual needs of the

patient.

Support with QOF outputs for the year and any other

areas within PCN.

Maintain the various long term condition registers,

update as necessary and send the associated recall letters.

Maintain the cervical cytology system, check

routine cytology recall lists, input results and send appropriate recall and

referral letters.

Send reminder, invitation and ad-hoc letters to patients

as required/appropriate.

Construct and maintain templates in conjunction

with clinical staff.

Monitor and action all e-mails sent to the generic

surgery e-mail account throughout the day as per our protocol.

Carrying out searches and interrogating the system

to provide necessary audits and reports, on both a periodic and ad hoc basis as

required by the management and clinical teams.

Read coding of information into the

practice clinical system consistently, accurately and in a timely manner to ensure

safe practice as required.

Check GP pathology results each

morning, matching unmatched patient results and allocating any unallocated

results. Share out the results of GPs

not on duty that day.

To drive wellbeing within the practice

with Staff and patients.

Other duties as agreed with the

Partnership.

This Job Description is not exhaustive and duties

may vary from time to time dependent upon the requirements of the business.

Bridge Surgery is a very friendly, supportive, well organised GMS training practice with:

Experience

Essential: - Experience of Microsoft Office packages e.g. PowerPoint, Word, Excel and other IT skills acquired through training or practical skills

Desirable: - Working in Primary Care