Care Coordinator

Help people 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.

Work collaboratively with GPs and other primary care

professionals within the practice to proactively identify and manage a

caseload, which may include patients with long-term health conditions, and

where appropriate, refer back to other health professionals at our PCN or

within our community service.

Work with people, their families, carers and healthcare

team members to encourage effective help-seeking behaviours.

Support our digital team in developing communication

channels between GPs, people and their families and carers and other agencies.

Maintain records of referrals and interventions to

enable monitoring and evaluation of the service. Conduct follow-ups on communications from out of

hospital and in-patient services.

Maintain records of referrals and interventions to

enable monitoring and evaluation of the service.

Support practices to keep care records up to date by

identifying and updating missing or out-of-date information about the persons circumstances.

Contribute to risk and impact assessments, monitoring

and evaluations of the service.

Work

with commissioners, integrated locality teams and other agencies to support and

further develop the role.

Enable access to personalised care and support

Take referrals for individuals or proactively identify

people who could benefit from support through care coordination.

Have a positive, empathetic and responsive conversation

with the person and their family and carer(s) about their needs.

Work towards increasing patients understanding of how

to manage and develop health and wellbeing through offering advice and guidance.

Develop an in-depth knowledge of the local health and

care infrastructure and know how and when to enable people to access support

and services that are right for them.

Use tools to measure peoples levels of knowledge,

skills and confidence in managing their health and to tailor support to them

accordingly.

Support people to develop and implement personalised

care and support plans.

Review and update personalised care and support plans

at regular intervals.

Ensure personalised care and support plans are

communicated to the GP and any other professionals involved in the persons

care and uploaded to the relevant online care records, with activity recorded

using the relevantSNOMED codes.

Coordinate and integrate care

Making and managing appointments for patients, related

to primary, secondary, community, local authority, statutory, and voluntary

organisations

Refer onwards to social prescribing link workers and

health and wellbeing coaches where required.

Regularly liaise with the range of multidisciplinary

professionals and colleagues involved in the persons care, facilitating a

coordinated approach and ensuring everyone is kept up to date so that any

issues or concerns can be appropriately addressed and supported.

Actively participate in multidisciplinary team meetings

in the PCN as and when appropriate.

Identify when action or additional support is needed,

alerting a named clinical contact in addition to relevant professionals, and

highlighting any safety concerns.

Record what interventions are used to support people,

and how people are developing on their health and care journey,

Keep accurate and up-to-date records of contacts,

appropriately using GP and other records systems relevant to the role, adhering

to information governance and data protection legislation.

Work sensitively with people, their families and carers

to capture key information, while tracking of the impact of care coordination

on their health and wellbeing.

Encourage people, their families and carers to provide

feedback and to share their stories about the impact of care coordination on

their lives.

Record and collate information according to agreed

protocols and contribute to evaluation reports required for the monitoring and

quality improvement of the service.

Miscellaneous

Establish strong working relationships with GPs and

practice teams and work collaboratively with other care coordinators, social

prescribing link workers and health and wellbeing coaches, supporting each

other, respecting each others views and meeting regularly as a team.

Act as a champion for personalised care and shared

decision making within the practice.

Demonstrate a flexible attitude and be prepared to

carry out other duties as may be reasonably required from time to time within

the general character of the post or the level of responsibility of the role,

ensuring that work is delivered in a timely and effective manner.

Identify opportunities and gaps in the service and

provide feedback to continually improve the service and contribute to business planning.

Contribute to the development of policies and plans

relating to equality, diversity and reduction of health inequalities.

Work in accordance with the practices policies and procedures.

Contribute to the wider aims and objectives of the practice

and our PCN to improve and support primary care.

We provide General Medical

Services to our patients from 2 sites in Southend:

Thorpe Bay surgery, Tyrone Road

Southend-on-Sea SS1 3HD

Tel 01702 582670

North Shoebury Surgery,

Frobisher Way, Shoeburyness, Essex SS3 8UTTel 01702 297976

Working together in

partnership with our Primary Care Network to deliver services to their patient population across both

practice sites, the practice is clinically lead by a GP and an Advanced Clinical

Practitioner, the partners are supported by a diverse clinical team made up of

salaried GPs and part time locum GPs, Advanced Nurse Practitioners, Associate

Nurse Practitioners, Prescribing Paramedics, Practice nurses, GP Nurse

Assistant, Health Care Assistants, a Lead Pharmacy Technician, Pharmacy

Technicians, and a Prescription Clerks.

The administration team

comprise of Care Navigators, Care Co-Ordinators, Medical secretaries, administration

staff, Assistant Manager, Practice Manager, Primary care Development Manager

and Business Manager with a list size in excess of 15,500 patients.

We are very proud to be a Training Practice

supporting GP and Nurse Training across South East Essex.

Whilst our practice

registration is growing, we strive to provide high quality, safe, efficient,

and effective service within the resource allocated to the practice. With particular focus on the prevention of

disease by promoting health and wellbeing, offering care and advice to our

patients.

Additional Requirements

Qualifications

Experience