Care Coordinator for Proactive Care
Key responsibilities The aim of Proactive Care is to provide proactive and personalised healthcare for people with multiple long-term conditions, including frailty, delivered through multi-disciplinary teams in local communities. Help patients in the community living with moderate or severe frailty, people experiencing health inequalities and those relying on unplanned care to manage their conditions where integrated community based support could better support individuals to manage their healthcare needs.
Working with clinicians to provide support in neighbourhood areas with an emphasis on self-management and prevention of avoidable illness. Provide coordination and navigation for health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support.Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, and where appropriate, refer back to other health professionals within the PCN. Support the coordination and delivery of multidisciplinary teams with the PCN.
Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision making conversations. Carry out holistic assessments to identify patients in the community that could benefit from healthcare intervention.
Aid patients in managing any long term conditions they may have, supporting self management and access to care. Support PCNs in developing communication channels between GPs and other agencies; Maintain records of referrals and interventions to enable monitoring and evaluation of the service; Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the patient's circumstances; Contribute to risk and impact assessments, monitoring and evaluations of the service; Work with commissioners, integrated locality teams and other agencies to support and further develop the role.
Key Tasks 1. Enable access to personalised care and support a. Take referrals for individuals or proactively identify patients who could benefit from support through care coordination; b. Have a positive, empathetic and responsive conversation with the patient about their needs; c.Support patients to develop and implement personalised care and support plans; d. Review and update personalised care and support plans at regular intervals; e. Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the patient's care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes; 2.
Coordinate and integrate care a. Help to transition seamlessly between services and support themto navigate through the health and care system; b. Refer onwards to appropriate health care professionals such as, social prescribing link workers, voluntary sector workers and health and wellbeing coaches where required; c.
Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the patient's care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported; d.
Actively participate in multidisciplinary team meetings in the PCN and individual practices as and when appropriate; e. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.
f. Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation; g. Work sensitively with patients to capture key information, while tracking of the impact of care coordination on their health and wellbeing; h.
Encourage patients to provide feedback and to share their stories about the impact of care coordination on their lives; i. Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service.
3. Professional development a. Work with a named clinical point of contact for advice and support. b. Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required; c.
Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety. 4. Miscellaneous a. Establish strong working relationships with GPs and practice teams and work collaboratively with other care coordinators, social prescribing link workers and health and wellbeing coaches, supporting each other, respecting each others views and meeting regularly as a team; b.
Act as a champion for personalised care and shared decision making within the PCN; c. Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner; d.Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning; e. Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities; f.
Work in accordance with the practices and PCNs policies and procedures g. Duties may vary from time to time without changing the general character of the post or the level of responsibility h. Contribute to the wider aims and objectives of the PCN to improve and support primary care.
i. To support in the delivery of the PCN Network DES, enhanced services and other service requirements on behalf of the PCN.