Care Coordinator in London

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 work closely with the patient and their clinician or other healthcare professional and understand the roles of various 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 receive the most suitable care from the relevant health or social care provider.

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:

• Respecting all
• Showing courtesy
• Seeking to understand
• Treating all fairly
• Valuing each person as a unique individual
• Being especially supportive to the vulnerable
• Working as a team
• 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 can 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. Patients and their families have the right to be treated fairly and to be routinely involved in decisions about their treatment and care. They can expect to be treated with dignity and respect and will not be discriminated against on any grounds including age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation.

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. It is essential that all staff protect patient information and provide a confidential service.

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. Effective communication is essential, and all staff must ensure that they communicate in a manner which enables the sharing of information appropriately.

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.

Leave:

All personnel are entitled to take leave. Line managers are to ensure that all of their staff are afforded the opportunity to take leave each year and should be encouraged to take all of their leave entitlement.

Main Duties & Responsibilities:

Core functions, but not limited to:

• 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 into a single personalised care and support plan (PCSP)
• Work across DCM Primary Care to manage the needs of patients in Care Homes, supported accommodation or trying to remain living at home
• Ensure all patients receive enhanced care in a timely fashion
• Support with performance/KPIs dashboards
• Undertake audits for dashboards/KPIs
• Support with any admin related task to the central team
• Work as part of a multi-disciplinary team in a patient facing role
• Provide personalised support to individuals, their families and carers
• Proactively identify and work with a cohort of people to support their personalised care requirements
• Ensure regular and consistent communication with the referrer regarding patient progress
• Support national screening and immunisation programmes and health checks/screening
• Monitor referrals to ensure tasks are completed and care delivered
• Direct liaison with multiple agencies to coordinate care for patients
• Refer to social prescribing link workers or health coaches where appropriate
• Support patient/carer contact roles and collate feedback on their experiences
• Raise awareness of shared decision-making and decision support tools
• Assist people to access self-management education courses
• 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
• Support the coordination and delivery of MDTs for their patient cohort

Administrative duties:

• Process registering new patients and entering their details on the computer system
• 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
• Complete admin tasks and support with AccuRx Total Triage
• Ensure that the system is operational at the beginning of each day

Clerical Duties:

• Ensure that prescriptions are handled accurately and efficiently
• Monitor incoming electronic test results
• Data entry of new and temporary registrations
• Scan all patient information in computerised record
• Deal with referrals to primary and secondary care
• Action tasks set by clinicians via the clinical systems and email

Secondary responsibilities:

• Participate in practice audit as directed by the audit lead
• Provide lunch cover where needed
• Undertake any other duties required by the needs of the practice
• Participate in appraisal scheme
• 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.

Experience: Experience of working in a primary care setting.

Skills:

• Excellent communication skills (written and oral)
• Good IT skills
• Effective time management
• Ability to listen, empathise with people and provide person-centred support
• Commitment to reducing health inequalities
• Ability to work as a team member and autonomously

Personal qualities:

• Polite and confident
• Flexible and cooperative
• Motivated
• High levels of integrity and loyalty
• Sensitive and empathetic in distressing situations
• Ability to work under pressure

Other requirements:

• Flexibility to work outside of core office hours
• Disclosure Barring Service (DBS) check
• Access to own transport and ability to travel across the locality regularly