Care Coordinator (Care Home Team)

Job responsibilities In your role you will work as a key part of the PCN multidisciplinary team. You will provide extra time and expertise to support care home patients in preparing for or in following up clinical conversations they have with primary care professionals. Helping people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care. Using tools to understand peoples level of knowledge and confidence skills in managing their own health. Acting as a point of contact between GPs, PCN care homes Nurses, practice staff, patients, carers and other agencies. You will liaise with GPs and the PCN care homes Nurses to identify care home patients who are elderly, frail or who have long term health needs and coordinate support appropriately. Support the care homes Nurses to manage care home patients on the PCNs case load, responding to on-demand needs of the care homes and following any unplanned hospital admissions where appropriate. Organise and participate in MDT meetings to discuss patients actively being managed by the Care Homes Team needing discussion. Maintain a weekly register of hospital admissions to be shared with practices. Maintain a weekly register of hospital discharges to be shared with practices. Maintain a weekly register of care homes deaths. Raise awareness of health promotion, screening and NHS Health Checks and Learning Disability Health Checks in practices. Document and monitor aspects of patient co-ordination and service delivery, supporting data collection and audit using the practices clinical system and coding contacts correctly into patient records. Demonstrate the ability to recognise and respond appropriately when faced with a sudden deterioration or emergency situation, alerting the team or enabling a rapid response. Support national screening and immunisation programmes and encourage uptake. Monitor referrals to ensure tasks are completed and care delivered by keeping in regular telephone contact with the care homes you support. Job description Job responsibilities Job responsibilities In your role you will work as a key part of the PCN multidisciplinary team. You will provide extra time and expertise to support care home patients in preparing for or in following up clinical conversations they have with primary care professionals. Helping people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care. Using tools to understand peoples level of knowledge and confidence skills in managing their own health. Acting as a point of contact between GPs, PCN care homes Nurses, practice staff, patients, carers and other agencies. You will liaise with GPs and the PCN care homes Nurses to identify care home patients who are elderly, frail or who have long term health needs and coordinate support appropriately. Support the care homes Nurses to manage care home patients on the PCNs case load, responding to on-demand needs of the care homes and following any unplanned hospital admissions where appropriate. Organise and participate in MDT meetings to discuss patients actively being managed by the Care Homes Team needing discussion. Maintain a weekly register of hospital admissions to be shared with practices. Maintain a weekly register of hospital discharges to be shared with practices. Maintain a weekly register of care homes deaths. Raise awareness of health promotion, screening and NHS Health Checks and Learning Disability Health Checks in practices. Document and monitor aspects of patient co-ordination and service delivery, supporting data collection and audit using the practices clinical system and coding contacts correctly into patient records. Demonstrate the ability to recognise and respond appropriately when faced with a sudden deterioration or emergency situation, alerting the team or enabling a rapid response. Support national screening and immunisation programmes and encourage uptake. Monitor referrals to ensure tasks are completed and care delivered by keeping in regular telephone contact with the care homes you support.