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.

Key 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

Skills, Knowledge and Expertise

• Excellent communication skills (written and oral)
• A clear understanding of child protection policy and procedures and commitment to the safeguarding of children and vulnerable adults
• Experience in use of the Patient Activation Measure (PAM)
• Good IT skills
• Clear, polite telephone manner
• Good knowledge of MS Office and Outlook
• EMIS/SystmOne/Vision user skills
• Effective time management (planning and organising)
• Ability to listen, empathise with people and provide person‑centred support in a non‑judgemental way
• Courteous, respectful and helpful at all times
• Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity
• Commitment to reducing health inequalities and proactively working to reach people from all communities
• Able to support people in a way that inspires trust and confidence, motivating others to reach their potential
• Ability to use own initiative, discretion and sensitivity
• Ability to work as a team member and autonomously
• Good interpersonal skills
• Problem solving and analytical skills
• Ability to follow policy and procedure

Benefits

• 20 days of annual leave, in addition to bank holidays (increasing with length of service)
• Access to NHS Discount Scheme
• Career progression opportunities within a growing organisation
• A collaborative and inclusive team culture across clinical and technical functions