Care Co-Ordinator Role (ARRS) in Redcar

Responsibilities

• You will work with GP Practice teams to coordinate the care of patients with frailty, cancer, long‑term conditions, safeguarding and social issues, patients requiring proactive care, and patients who require support to communicate effectively.
• You will liaise with patients, practice teams, secondary care teams, social services, the voluntary and community sector, and other members of the Primary care Network to help smooth the patient’s pathway, expedite care where appropriate, and follow up letters and results.
• You will support the practice to deliver good‑quality care for frail patients, patients in palliative care, and patients with long‑term conditions, and prepare for effective GSF and frailty meetings.
• You will ensure that processes such as falls assessments and medication reviews are carried out in a timely manner.
• You will help develop a personalised care and support plan for these patients where appropriate, ensuring they are reviewed at an appropriate frequency and that the practice achieves QOF, IIF, LIS & DES targets.
• You will work as part of the Redcar Coastal PCN team to support the patients of seven GP Practices.
• You will proactively identify patients who require care coordination using agreed criteria and population health tools, support the delivery of the practice GSF and frailty programmes, and support the achievement of practice quality standards.
• You will work closely with Social Prescribing Link Workers to address wider determinants of health such as poor housing, debt stress and loneliness, and identify and prioritise care/support needs in a single, personalised care plan based on what matters to the person in a shared decision‑making process.
• You will help patients manage their needs by answering queries, making and managing appointments, and ensuring people have access to good‑quality information about their care.
• You will coordinate appointments and encourage uptake of vaccinations in eligible populations, assess people to access personal health budgets, and encourage uptake of QOF LTC Annual and Structured Medication Reviews.
• You will encourage the delivery of good‑quality annual health checks for patients with Learning Disabilities and SMI.
• You will support the practice in delivering its IIF priorities.
• You will support cancer screening, including FIT tests/bowel screening, cervical screening and breast screening, refer smokers to smoking cessation, and coordinate and follow up referrals and appointments.
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