Clinical Services Care Co-Ordinator in Canterbury

The Clinical Services Care Coordinator is primarily responsible for supporting the Clinical Services Team with the delivery and coordination of services offered by the practice and the wider Primary Care Network (PCN). The focus of the role is to support high-quality, personalised care for patients through effective care coordination, navigation and administrative systems, with a particular focus on patients with long-term conditions, multiple needs and those who may benefit from additional support.

The Care Coordinator will work closely with GPs, nurses and other primary care professionals, as well as Social Prescribing Link Workers, Health and Wellbeing Coaches and other members of the wider health, care and voluntary sector. The role will combine proactive population health activity with individual care coordination, helping patients to understand and manage their health and wellbeing and ensuring they are connected with the right services and support.

Key Responsibilities:

• Work with GPs and other primary care professionals to identify and manage an appropriate caseload of patients.
• Use population health information and EMIS searches to proactively identify patients who may benefit from support.
• Support patients to develop personalised care and support plans based on what matters to them.
• Support shared decision making and use of appropriate decision aids.
• Help patients access self-management support, social prescribing, community and voluntary services, employment/training opportunities and other appropriate resources.
• Provide care navigation and coordination across health, social care and community services.
• Coordinate appointments, reviews, home visits and other services where required.
• Support the coordination and delivery of multidisciplinary team (MDT) meetings.
• Support long-term condition management, patient recalls, health promotion and proactive care.
• Undertake EMIS searches, audits and monitoring activity.
• Use relevant systems including EMIS, Ardens and iPlato.
• Liaise with patients, carers, clinicians and external organisations.
• Support QOF, Enhanced Services, PCN DES, IIF and other Clinical Services activity.
• Maintain accurate records and ensure information is handled in accordance with GDPR and confidentiality requirements.

Training and Development:

The practice will support the successful candidate to complete the training required for the ARRS Care Coordinator role where this is not already held. This will include, as appropriate, Personalised Care Institute-accredited Care Coordinator training, personalised care and support planning, shared decision making and relevant practice/PCN training. Appropriate supervision and ongoing professional development will be provided.

Confidentiality:

In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately. In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. All such information from any source is to be regarded as strictly confidential.

Health & Safety:

The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the practice Health & Safety Policy, the practice Health & Safety Manual, and the practice Infection Control policy and published procedures.

Equality and Diversity:

The post-holder will support the equality, diversity and rights of patients, carers and colleagues.

Personal/Professional Development:

The post-holder will participate in any training programme implemented by the practice as part of this employment.

Quality:

The post-holder will strive to maintain quality within the practice.

Communication:

The post-holder should recognize the importance of effective communication within the team.

Contribution to the Implementation of Services:

The post-holder will apply practice policies, standards and guidance.