Care Coordinator - Horsham Central PCN
NHS Jobs Horsham
Key Responsibilities and Duties 1. To support adult patients and assist them through the healthcare system by acting as a patient advocate and navigator, empowering them and educating them to promote and support their independence. 2. Use practice data to make informed decision, identify inequalities and initiate projects to improve services and the lives of our patients and community.
3. To talk to patients, and where appropriate their families and/or carers, on the practice premises, remotely by telephone or video, or in the patients home if needed. 4. Liaise with Care Homes as necessary. MDT Coordination 1. Overall responsibility for arranging MDT meetings and the smooth running of integrated care within the medical centre.
A key role of the Care Coordinator will be to schedule the MDT meetings and manage the meeting agenda items, ensuring that all new referrals are identified, and information is circulated to team members in advance of the meeting. 2. Identify patients to discuss at PCN level MDTs with a view to reducing unplanned admissions and exacerbation of conditions.
Managing a caseload 1. Identify patients that may need support by receiving information about transfers of care (including hospital admissions and discharges) and from internal practice intelligence. 2. Educate patients (and if applicable and if appropriate consent is in place, their carers or family) about their condition and medication, and give them specific instructions.
3. Help patients understand their condition by liaising with clinical colleagues, especially the practice pharmacy team, regarding their medication. Aim for patients to have specific instructions regarding their medication and understand how they access repeat prescriptions and reviews.
4. With the help of relevant clinical colleagues, develop a care plan to address patients personal health care needs. Ensure care plans are maintained, updated, and uploaded to all relevant systems for sharing with other providers, including SystmOne and ShareMyCare.
5. Promote clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans. 6. Assist and empower the patient to consult and collaborate with other health care providers and specialists to set up patient appointments and treatment plans.
7. Check in on the patient regularly and evaluate and document their progress. Linking with other services 1. Signpost team members, service users and carers to relevant services including the PCN Social Prescribing Link Worker Service. 2. Liaise with the Social Prescriber and Mental Health Support Coordinator regarding patients that are identified as needing well-being support.
3. Liaise with practice clinicians responsible for frailty regarding patients that are identified as needing ongoing support. 4. Liaise with acute trusts, care homes, hospices, community and social care providers as required. Record Keeping 1. Keep accurate and up-to-date records of contact with patients, carers and professionals, including use of SystmOne to record patient contact on the medical record.
2. Use accurate SNOMED codes to record patient contacts and interventions, mainly via the use of provided templates, for audit purposes and monitoring and measuring outcomes. 3. Manage reporting required and associated within the DES specifications for required services e.g IIF and other services such as EA. 4. Report case studies and outcomes to the PCN on a quarterly basis.
General Responsibilities 1. Work as part of the team to seek feedback, continually improve the service and contribute to business planning. 2. Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner.
3. Attend ongoing training and courses to keep abreast of new developments in health care. 4. Treat patients with empathy and respect and conduct oneself in a professional manner. 5. Attend and contribute to relevant meetings. 6. Duties may vary from time to time, without changing the general character of the post or the level of responsibility.
3. To talk to patients, and where appropriate their families and/or carers, on the practice premises, remotely by telephone or video, or in the patients home if needed. 4. Liaise with Care Homes as necessary. MDT Coordination 1. Overall responsibility for arranging MDT meetings and the smooth running of integrated care within the medical centre.
A key role of the Care Coordinator will be to schedule the MDT meetings and manage the meeting agenda items, ensuring that all new referrals are identified, and information is circulated to team members in advance of the meeting. 2. Identify patients to discuss at PCN level MDTs with a view to reducing unplanned admissions and exacerbation of conditions.
Managing a caseload 1. Identify patients that may need support by receiving information about transfers of care (including hospital admissions and discharges) and from internal practice intelligence. 2. Educate patients (and if applicable and if appropriate consent is in place, their carers or family) about their condition and medication, and give them specific instructions.
3. Help patients understand their condition by liaising with clinical colleagues, especially the practice pharmacy team, regarding their medication. Aim for patients to have specific instructions regarding their medication and understand how they access repeat prescriptions and reviews.
4. With the help of relevant clinical colleagues, develop a care plan to address patients personal health care needs. Ensure care plans are maintained, updated, and uploaded to all relevant systems for sharing with other providers, including SystmOne and ShareMyCare.
5. Promote clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans. 6. Assist and empower the patient to consult and collaborate with other health care providers and specialists to set up patient appointments and treatment plans.
7. Check in on the patient regularly and evaluate and document their progress. Linking with other services 1. Signpost team members, service users and carers to relevant services including the PCN Social Prescribing Link Worker Service. 2. Liaise with the Social Prescriber and Mental Health Support Coordinator regarding patients that are identified as needing well-being support.
3. Liaise with practice clinicians responsible for frailty regarding patients that are identified as needing ongoing support. 4. Liaise with acute trusts, care homes, hospices, community and social care providers as required. Record Keeping 1. Keep accurate and up-to-date records of contact with patients, carers and professionals, including use of SystmOne to record patient contact on the medical record.
2. Use accurate SNOMED codes to record patient contacts and interventions, mainly via the use of provided templates, for audit purposes and monitoring and measuring outcomes. 3. Manage reporting required and associated within the DES specifications for required services e.g IIF and other services such as EA. 4. Report case studies and outcomes to the PCN on a quarterly basis.
General Responsibilities 1. Work as part of the team to seek feedback, continually improve the service and contribute to business planning. 2. Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner.
3. Attend ongoing training and courses to keep abreast of new developments in health care. 4. Treat patients with empathy and respect and conduct oneself in a professional manner. 5. Attend and contribute to relevant meetings. 6. Duties may vary from time to time, without changing the general character of the post or the level of responsibility.
Please see full Job Description for further information.
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