Care Coordinator

The Care Coordinator role is seen as a critical

and evolving post to support the multi-disciplinary teams (MDTs) within the PCN

to deliver effective, co-ordinated and personalised care for patients in care

homes and for a cohort of elderly and frail patients.

The post holder will work closely with teams to

help and support the multi-disciplinary team (MDT) this will include the

on-going patient case management. This will involve working with the GP surgeries

and linking in with a range of community health and social care services, care

homes and third party services.

The post holder will demonstrate excellent

organisational and communication skills, be flexible in their approach, able to

exercise initiative and demonstrate consistently high standards of

professionalism. The post holder must at all times be aware of the need for

confidentiality and integrity. They will also need a basic knowledge of Health

and Social Care terminology and eligibility criteria and current team

structures and pathways.

Key working relationships

Patients, patients families and carers

GPs, nurses and other practice staff

Care home managers, clinicians, carers and staff

Case Manager and Geriatrician

Community nurses and other allied health professionals

Community pharmacists and support staff

Responsibilities underpinning the role

The Care Coordinator has the following key

To assist the team to develop one single personalised

care and support plan for patients to be held on the patients medical records

and in the care homes. Holistically bring together all of a patients

identified care and support needs, and explore options to meet these with a

single personalised care and support plan (PCSP), in line with PCSP best

practice, based on what matters to the person.

To assist the team to develop one single personalised

care and support plan for patients to be held on the patients medical records

and in the care homes. Holistically bring together all of a patients

identified care and support needs, and explore options to meet these with a

single personalised care and support plan (PCSP), in line with PCSP best

practice, based on what matters to the person.

patients to manage their needs by answering queries, assisting with making/

managing appointments, and ensuring that patients have good verbal or written

information to help them make choices about their care.

coordination and navigation for patients and their carers across health and

social care services, working closely with social prescribing link workers and

other primary care professionals. Explore and assist people to access personal

health budgets or appropriate benefits where eligible.

Support

patients to utilise decision aids in preparation for a shared decision making

conversation.

with GPs and other primary care professionals within the PCN to identify and

manage a caseload of patients, and where required and as appropriate, refer

patients back to other health professionals within the PCN.

awareness within the PCN of shared decision making and decision support tools.

Raise awareness of how to identify patients who may benefit from shared

decision making and support PCN staff and patients to be more prepared to have

shared decision making conversations.

To act as first point of contact for professionals,

GPs, care homes, community services and the third sector.

Responsible for the organisation of MDT meetings and supporting

the coordination and delivery of MDTs within the PCN.

Responsible

for a register of patients identified at PCN MDT coordinating patient care

across services and the PCN.

Review

discharge summaries and conduct post discharge follow up call to review patients

needs and arrange a package of care if needed.

Manage

the recall of patients in need of bloods/BPs and other diagnostic test for

medication reviews and/or green eclipse alerts.

act as a support contact for elderly and frail patients.

support end of life care and palliative care.

provide support for patients with learning disabilities.

follow appropriate safeguarding procedures.

Administrative Reponsibilities

To work as a key member of the MDT to help support the

development of effective MDT meetings.

take a lead in IT ensuring all MDT staff have access to Microsoft Teams and

have adequate equipment to participate in video meetings.

Lead on the IT facilitation of the MDT meetings using

Microsoft teams including sending out invites to appropriate members of the

MDT.

To take minutes of MDT meetings and ensure that action

points identified are recorded and followed up within a set timescale.

Under guidance from their line manager take initiative

in the organisation and administration of MDT working to minimise the demands

upon the multidisciplinary team.

To work with the wider MDT to identify appropriate case

managers* for high-risk patients to ensure that patients are reviewed, and

anticipatory care plans are developed

Ensure that all patients Anticipatory Care Plans,

diagnostics results and associated correspondence are available to the MDT,

liaising with all agencies as appropriate, accessing IT systems to ensure

relevant information is available

To liaise with acute hospitals and coordinate the

sharing of key information between the acute hospital teams and the MDT team.

Act

as a non-clinical contact for the care home to assist with case management of

patients at risk of admission; working with the ANP / GP to identify sources of

support in liaison with case managers.

To

accurately read code and update/maintain patients records for anticipatory

care.

update care plan templates within Systm1 ensuring accuracy with read codes

used.

Maintain

an accurate record of two week wait referrals for practice audits.

To

provide support with safeguarding admin (adults and child).

Under the guidance of case managers assist with the

discharge process to reduce length of stay in the acute / community hospital

setting

This

list is not exhaustive and may be subject to change.

Workforce Responsibility

The post holder must remain up to date with mandatory

training as required

The post holder will be required to drive

The post holder may be required to undertake duties at

any location in the community in order to meets service needs

Concentration required for data analysis, tracking

patients and meetings, frequent interruptions requiring attention and

re-prioritisation of work

Input data for a significant period

Arbennek Healthcare is committed to an equal opportunities policy

that affirms that all staff should be afforded equality of treatment and

opportunity in employment irrespective of sexuality, marital status, race,

religion/belief, ethnic origin, age, or disability. All staff are required to

observe this policy in their behaviour to fellow employees.

Arbennek PCN is located in the central ICA within the Cornwall

and Isles of Scilly Integrated Care System and has approximately 32,453 people

registered from 4 GP Practices Brannel Surgery, Clays Surgery, Probus Surgery

and Roseland Surgeries.

The post holder will work a majority of their time out of Brannel Surgery

Qualifications