Care Coordinator

The Care Coordinator (CC) may be required to deal with patients and, if appropriate, their carers, before or after the patient’s consultation with a clinician or other healthcare professional. The CC’s role requires them to be able to work closely with the patient and their clinician or other healthcare professional and understand the roles of a variety of different people working in the practice and across the PCN. The CC will be involved in coordinating patients’ healthcare and directing them to the appropriate service to ensure that they get the most suitable care from whatever health or social care provider is appropriate.

You may be given a caseload of identified patients and be required to ensure that their changing or present needs are addressed by taking into account local priorities, health inequalities and/or population health management risk stratification.

Core Values:

• Showing courtesy
• Seeking to understand
• Treating all fairly
• Valuing each person as a unique individual
• Being especially supportive to the vulnerable

Teamwork:

• Relating well within the team
• Valuing the contribution of each team member
• Building a mutually supportive environment
• Co-operating with other teams
• Encouraging responsible involvement by our patients

Integrity:

• Speaking and acting truthfully
• Being accountable for our actions

Learning and Improving:

• Adapting to change
• Building on achievements
• Developing our services

Equality, Diversity & Inclusion:

A good attitude and positive action towards Equality Diversity and Inclusion (EDI) create an environment where all individuals are able to achieve their full potential. Creating such an environment is important for three reasons: it improves operational effectiveness, it is morally the right thing to do, and it is required by law.

Safety, Health, Environment and Fire (SHEF):

This practice is committed to supporting and promoting opportunities for staff to maintain their health, well-being and safety. You have a duty to take reasonable care of health and safety at work for you, your team and others, and to cooperate with employers to ensure compliance with health and safety requirements.

Confidentiality:

This practice is committed to maintaining an outstanding confidential service. Patients entrust and permit us to collect and retain sensitive information relating to their health and other matters pertaining to their care.

Quality & Continuous Improvement (CI):

To preserve and improve the quality of our output, all personnel are required to think not only of what they do but how they achieve it. By continually re-examining our processes, we will be able to develop and improve the overall effectiveness of the way we work.

Induction Training:

On arrival at the practice, all personnel are to complete a practice induction programme.

Learning and Development:

The effective use of training and development is fundamental in ensuring that all staff are equipped with the appropriate skills, knowledge, attitude and competences to perform their role.

Collaborative Working:

All staff are to recognise the significance of collaborative working. Teamwork is essential in multidisciplinary environments.

Service Delivery:

Staff at DMC must adhere to the information contained within practice policies and regional directives, ensuring that protocols are adhered to at all times.

Security:

The security of the practice is the responsibility of all personnel. Staff must ensure that they remain vigilant at all times and report any suspicious activity immediately to their line manager.

Professional Conduct:

At DMC staff are required to dress appropriately for their role.

Main Duties & Responsibilities:

• Support Quality and Outcome Frameworks, PCN and other LES and DES specifications
• Maintain and develop engagement with appropriate DCM colleagues and encourage ‘best practice’
• Act as the first port of call for patients, in their caseload in relation to their care.
• Support and Manage clinical call and recall
• Bring together all of a person’s identified care and support needs, and explore their options to meet these into a single personalised care and support plan (PCSP)
• Working across DCM Primary Care to manage the needs of patients in Care Homes, supported accommodation or trying to remain living at home
• Performance targets - Ensure all patients receive enhanced care in a timely fashion and any other aspect of managing the patient facing service.
• Support with the performance/KPIs dashboards.
• Undertake audits for dashboards/KPIs
• Support with any admin related task to the central team
• To work as part of a multi-disciplinary team in a patient facing role to assess and respond to patients and colleagues using their expert knowledge
• To be responsible for arranging assessment of new patients with subsequent production and completion of individual care plans by appropriate clinicians
• To provide personalised support to individuals, their families and carers to ensure that they are active participants in their own healthcare and to empower them to take more control in managing their own health and well-being, to live independently and to improve their health outcomes
• Undertake work in line with PCN directed priorities.
• Proactively identify and work with a cohort of people to support their personalised care requirements, using the available decision support aids
• Ensure regular and consistent communication with the referrer regarding patient progress and any complications or guidance
• Support national screening and immunisation programmes and health checks/screening
• Monitor referrals to ensure tasks are completed and care delivered by keeping in regular telephone contact
• Direct liaison with multiple agencies to coordinate care for patients
• Refer to social prescribing link workers or health coaches where a patient is identified as potentially benefitting from this service
• To support patient/carer contact roles, and collate patient and carer feedback on their experiences
• Raise awareness of shared decision-making and decision support tools, and assist people to be more prepared to have a shared decision-making conversation
• Ensure that people have good quality information to help them make choices about their care
• Support people to understand their level of knowledge, skills and confidence – their “Activation” level – when engaging with their health and wellbeing, including using the Patient Activation Measure
• Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing
• Explore and assist people to access personal health budgets where appropriate.
• Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers and other primary care roles.
• Support the coordination and delivery of MDTs for their patient cohort

Administrative Duties:

• To process registering new patients, making up notes and entering their details on the computer system.
• To process new arrivals and deductions.
• To support with GP Links.
• Management of the generic inbox
• Scanning and coding all clinical documents.
• Using the electronic filing system to complete filing.
• Dealing with internal and external post
• To complete admin tasks and support with AccuRx Total Triage
• To undertake photo-copying and other basic office duties as directed by members of the team.
• To deal with queries for further information from hospitals or other local providers about patients.
• To assist in preparing and sending out practice correspondence.
• Ensure that the system is operational at the beginning of each day & switched on to the answer phone with the correct tape at lunchtime & at the end of each day.

Clerical Duties:

• Ensure that prescriptions are handled accurately and efficiently following protocol
• Monitor incoming electronic test results to ensure prompt review by clinicians
• Data entry of new and temporary registrations and relevant patient information e.g. smoking status, BP, ethnicity, medication from hospital letters
• Scan all patient information in computerised record i.e. medical documents, hospital reports and letters as necessary
• Deal with referrals to primary and secondary care
• Action tasks set by clinicians via the clinical systems and email
• Handling of document via clinical systems and practice protocols

Secondary Responsibilities:

• Participate in practice audit as directed by the audit lead
• To be flexible to cover shifts in the event of staff holidays and sickness.
• Provide lunch cover where needed.
• To undertake any other duties required by the needs of the practice & commensurate with the post.
• Following mandatory training - to act as a chaperone when required.
• To participate and contribute to team meetings and other meetings as required.
• To undertake training as required including mandatory and statutory training, core skills training and ongoing developmental training.
• To have knowledge of all Practice procedures.
• To work in accordance of written protocols.
• To participate in appraisal scheme.
• To present a positive image of the practice at all times.

Skills, Knowledge & Expertise:

Qualifications: The Care Coordinator is enrolled in, undertaking or qualified in appropriate training as set out by the personalised care framework. Passed training requirements as outlined by the Personalised Care Institute and fully understands the personalised care framework.