Job responsibilities
CARE COORDINATOR ROLE
Its estimated that one in five people who go to see their GP are troubled by things that cant be cured by medical treatment. GPs tell us they spend significant amounts of time dealing with the effects of poor housing, debt, stress and loneliness. Many people are overwhelmed and cant reach out to make the connections that could make a difference to their situation. This is especially true for people who have long-term conditions, who need support with their mental health, who are lonely or isolated, or who have complex social needs that affect their wellbeing. And thats where Care Coordinators come in. A Care Coordinator works as part of a multidisciplinary team (MDT) within the Practice to identify the people most in need of proactive support.
JOB DESCRIPTION
Act as a central point of contact within the Surgery for patients with non-medical needs.
Coordinate the patients journey through primary, secondary and community care by providing signposting and navigation of care and support across health and care services.
Provide support to vulnerable patients, including those with dementia, cancer and long-term conditions.
Ensure patients have good quality information to help them make choices about their care.
Develop personalised care and support plans, based on what matters to the patient, with emphasis on shared decision making and self-management. Ensure clinical care plans are reviewed in a timely manner.
Support the workload of GPs and other staff by supporting people to take more control of their health and wellbeing and addressing wider detriments of health, such as poor housing, debt, stress and loneliness.
Work closely with the Health and Wellbeing Team to ensure the patient receives the appropriate referral.
Organise patient invites for the PCN Virtual Group Clinics.
Coordinate referrals for monthly MDT meetings and follow up any action points arising from the meetings.
Support the practice in achieving QOF and IIF targets, particularly for those patients with long term conditions.
TRAINING AND DEVELOPMENT
Stay up to date through attendance at any courses and/or study days necessary to ensure that professional development requirements are met, demonstrating skills and activities to others who are undertaking similar work.
Subject to a performance review, including taking responsibility for maintaining a record of own personal and/or professional development.
Work closely with other clinical staff and administrative managers in the setting up and/or improving of practice systems for monitoring/measuring performance against Clinical Governance and Quality Indicator targets
Work to deliver the NHS contract requirements related to the practice (including the terms of the Quality and Outcomes Framework and locally enhanced services)
GOVERNANCE
- Produce complete and accurate records of patient consultation, in line with best practice, confidentiality, policies and procedures
- Deliver care according to NHS guidance, NICE guidelines and evidence-based care
- Take part in the maintenance of quality governance systems and processes across the Practice and its activities.
- Utilise the audit cycle as a means of evaluating the quality of the work of self and the team, implementing improvements where required.
- Work with other clinical teams on improving the quality of healthcare in response to local and national policies and initiatives as appropriate
- Evaluate patients response to health care provision and the effectiveness of care
- Support and participate in shared learning across the practice and wider organisation
- Manage, review and identify learning from patient complaints, clinical incidents and near-miss events
- Awareness of statutory safeguarding, notification processes and local guidance for children/vulnerable patients, applying relevant policies and legislation to protect them
- Ensure compliance with policies, procedures and guidelines for self and others, by taking action or alerting senior management team if the practice appears to contravene policy, or if there are concerns over any aspect of patient care.
HEALTH & SAFETY
- The post-holder will manage their own and others health & safety and infection control as defined in the Practices Health & Safety Policy, the Practice Health & Safety Manual, and the Practices Infection Control Policy and published procedures.
- Comply with Practice health and safety policies by following agreed safe working procedures
- Awareness and compliance with national standards of infection control, hygiene, regulatory / contractual / professional requirements, and good practice guidelines.
- Correct personal use of Personal Protective Equipment (PPE) and ensuring correct use of PPE by others, advising on appropriate circumstances for use by clinicians, staff and patients.
- Reporting incidents using the organisations Incident Reporting System
CONFIDENTIALITY
- Maintain confidentiality of information, acting within the terms of the Data Protection Act and Caldicott guidance on patient confidentiality at all times.
- Maintain an awareness of the Freedom of Information Act.
EQUALITY AND DIVERSITY
- The post-holder will support, promote and maintain the Practices Equality & Diversity Policy.
- No person whether they are staff, patient or visitor should receive less favourable treatment because of their gender, ethnic origin, age, disability, sexual orientation, religion etc.
- The jobholder must comply with all policies and procedures designed to ensure equality of employment and that services are delivered in ways that meet the individual needs of patients and their families.
OTHER DELEGATED DUTIES
This job description is not intended to be exhaustive - it may be changed after consultation with the post holder. The employee shares with the employer the responsibility for review and modification of duties.
