Care Coordinator

The Care Coordinator responsibilities include, but are not limited to the following: 1 . Work with GPs and other primary care professionals, including social prescriber link workers, to identify and manage a caseload of patients, 2. Coordination of care for patients across health, social care and mental health as appropriate, providing a single-point of access for staff & service users, actively managing patients' care plan delivery 2. Facilitating the smooth and planned discharge and handover between care settings across the health and social care system, including GP, acute, community, and be responsible for facilitating inter-agency communication and support 3. Identify and work with a list of named patients with the aim of encouraging independence, enabling people to remain at home, reducing unnecessary admissions to hospitals and supporting early discharge from hospital, improving the quality of care. 4. Provide feedback to the practices, troubleshoot and escalate actions as necessary, providing advocacy for service users. KEY DUTIES AND RESPONSIBILITIES 1 . Facilitate and ensure the effective delivery of patient-centred, personalised health and social care plans for patients, monitoring progress and reporting outcomes, contributing to patient reviews and care planning within appropriate time frames 2. Supporting patients to use decision aids , help create single personalised care and support plans in line with best practice. 3. Explain the management of a patient's pathway to clinical staff, liaising between services and service users, contacting services using the appropriate procedures/referral mechanisms and helping patients in making and managing appointments. 4. Work closely with all relevant care agencies (primary care, secondary care, community services, Social Prescribers, Link workers, Community Pharmacists, Mental Health, Social Services, Ambulance Service, Voluntary services and other relevant service providers) to ensure a coordinated patient care plan, without requiring a further referral from the GP. 5. Ensure that a proper handover of care between different settings has taken place, including mutual transfer of all organisations' communications & patient notes and ensuring care packages are set up 6. Collect data on patients/carers and ensure all patient notes are updated to reflect any changes, including details on plans. 7. Use healthcare technologies to optimise service delivery, access and coordinating care. 8. Organise and attend relevant meetings when required including Integrated Care meetings, ensure a programme of regular meetings is established, ensuring that all necessary documentation is circulated in advance. 9. Ensure that meeting actions are recorded, disseminated and followed up in a timely way; ensure relevant practitioners are aware of meeting decisions and actions / outcomes, and chase for action resolution and update. 10. Network and develop strong relationships with all levels of the NHS's key local players including the CCG, GPs and other primary care contractors, Social Services, Mental Health Trusts, Community Trusts, and other providers including the voluntary sector 11. Be a contact point for GPs / practices and establish systems and processes which will ensure a timely and appropriate response to queries from clinicians and other stakeholders 12. Identifying and working within the Primary Care teams to support personalised care for patients and bringing together all of a person's identified care and support needs to create a single personalised care and support plan. 13. Help people to manage their needs, answering their queries and supporting them to make appointments, follow ups and to advocate for them in their care journey. 14. Supporting people to take up training and employment accessing benefits where eligible and refer to social prescribers where appropriate. 15. Raising awareness of shared decision making and assisting people to have a shared decision-making conversation and ensuring that people have good quality information to help them make choices about their care. 16. Assisting people to access self-management education courses, peer support or interventions that support them in their health and wellbeing 17. To assist patients in streamlining their own care and onboarding to new technology such as the NHS Apps and use of practice websites for access. 18. To coordinate and manage the Patient Participation Groups in collaboration with Practice managers and clinical teams and to innovate ways to enhance engagement. 19. To Capture Patient Positive experiences and feedback to grow confidence within the practice and aid with the delivery of an effective patient journey, 20. Work within the policies of scheme and Practices. 21. Maintain a good working knowledge of health and safety procedures 22.Promote client involvement in the management of the service. 23. Participate in regular appraisals and practice reviews. 24. Attend training and development activities as identified and participate in meetings as required. 25. Maintain a good working knowledge of Health and Safety procedures and fire precautions, and operate the correct procedures and participate in policy development and data collection where appropriate. 26. Work flexibly to meet the needs of patients and be able to adapt to change 27. To undertake any other duties appropriate to the grade and purpose of the job as may be agreed by the post holder. This job description is intended to provide an outline of the key tasks and responsibilities only. There may be other duties required of the post-holder commensurate with the position. This description will be open to regular review and may be amended to consider development within the Organisation. All members of staff should be prepared to take onadditional duties or relinquish existing duties to maintain the efficient running of the Practice Job description Job responsibilities The Care Coordinator responsibilities include, but are not limited to the following: 1 . Work with GPs and other primary care professionals, including social prescriber link workers, to identify and manage a caseload of patients, 2. Coordination of care for patients across health, social care and mental health as appropriate, providing a single-point of access for staff & service users, actively managing patients' care plan delivery 2. Facilitating the smooth and planned discharge and handover between care settings across the health and social care system, including GP, acute, community, and be responsible for facilitating inter-agency communication and support 3. Identify and work with a list of named patients with the aim of encouraging independence, enabling people to remain at home, reducing unnecessary admissions to hospitals and supporting early discharge from hospital, improving the quality of care. 4. Provide feedback to the practices, troubleshoot and escalate actions as necessary, providing advocacy for service users. KEY DUTIES AND RESPONSIBILITIES 1 . Facilitate and ensure the effective delivery of patient-centred, personalised health and social care plans for patients, monitoring progress and reporting outcomes, contributing to patient reviews and care planning within appropriate time frames 2. Supporting patients to use decision aids , help create single personalised care and support plans in line with best practice. 3. Explain the management of a patient's pathway to clinical staff, liaising between services and service users, contacting services using the appropriate procedures/referral mechanisms and helping patients in making and managing appointments. 4. Work closely with all relevant care agencies (primary care, secondary care, community services, Social Prescribers, Link workers, Community Pharmacists, Mental Health, Social Services, Ambulance Service, Voluntary services and other relevant service providers) to ensure a coordinated patient care plan, without requiring a further referral from the GP. 5. Ensure that a proper handover of care between different settings has taken place, including mutual transfer of all organisations' communications & patient notes and ensuring care packages are set up 6. Collect data on patients/carers and ensure all patient notes are updated to reflect any changes, including details on plans. 7. Use healthcare technologies to optimise service delivery, access and coordinating care. 8. Organise and attend relevant meetings when required including Integrated Care meetings, ensure a programme of regular meetings is established, ensuring that all necessary documentation is circulated in advance. 9. Ensure that meeting actions are recorded, disseminated and followed up in a timely way; ensure relevant practitioners are aware of meeting decisions and actions / outcomes, and chase for action resolution and update. 10. Network and develop strong relationships with all levels of the NHS's key local players including the CCG, GPs and other primary care contractors, Social Services, Mental Health Trusts, Community Trusts, and other providers including the voluntary sector 11. Be a contact point for GPs / practices and establish systems and processes which will ensure a timely and appropriate response to queries from clinicians and other stakeholders 12. Identifying and working within the Primary Care teams to support personalised care for patients and bringing together all of a person's identified care and support needs to create a single personalised care and support plan. 13. Help people to manage their needs, answering their queries and supporting them to make appointments, follow ups and to advocate for them in their care journey. 14. Supporting people to take up training and employment accessing benefits where eligible and refer to social prescribers where appropriate. 15. Raising awareness of shared decision making and assisting people to have a shared decision-making conversation and ensuring that people have good quality information to help them make choices about their care. 16. Assisting people to access self-management education courses, peer support or interventions that support them in their health and wellbeing 17. To assist patients in streamlining their own care and onboarding to new technology such as the NHS Apps and use of practice websites for access. 18. To coordinate and manage the Patient Participation Groups in collaboration with Practice managers and clinical teams and to innovate ways to enhance engagement. 19. To Capture Patient Positive experiences and feedback to grow confidence within the practice and aid with the delivery of an effective patient journey, 20. Work within the policies of scheme and Practices. 21. Maintain a good working knowledge of health and safety procedures 22.Promote client involvement in the management of the service. 23. Participate in regular appraisals and practice reviews. 24. Attend training and development activities as identified and participate in meetings as required. 25. Maintain a good working knowledge of Health and Safety procedures and fire precautions, and operate the correct procedures and participate in policy development and data collection where appropriate. 26. Work flexibly to meet the needs of patients and be able to adapt to change 27. To undertake any other duties appropriate to the grade and purpose of the job as may be agreed by the post holder. This job description is intended to provide an outline of the key tasks and responsibilities only. There may be other duties required of the post-holder commensurate with the position. This description will be open to regular review and may be amended to consider development within the Organisation. All members of staff should be prepared to take onadditional duties or relinquish existing duties to maintain the efficient running of the Practice