Care Coordinator
As a member of The Clinical Support Team, you will be required to have a large degree of patient contact; this will be mostly via the telephone with some home visits when necessary. Liaison with carers, care homes, other outside agencies and in-house Social Prescribers.
In addition, the candidate will undertake various administration tasks including information analysis and data management. The team offers patients a holistic assessment, to help with a wide range of physical, social and mental health issues.
The aim of the team is to support these patients to remain as independent as possible in their own home by accessing care, benefits, mobility aids, advice, and many other areas that they may need help. The team also seeks to combat loneliness and isolation by supporting the work of the volunteer Telephone Befrienders and signposting patients to appropriate social opportunities.
Job Purpose Act as a patient advocate and care navigator To be a familiar point of contact for vulnerable patients and their families/carers Help navigate health and social care pathways for patients with complex needs To liaise with other members of the Multidisciplinary Team (MDT) To attend surgery meetings and feedback information regarding patients To ensure colleagues are made aware of any service changes, offering guidance and help as required Ensure electronic record keeping is maintained for each patient contact Key areas of responsibility and duty To help patients remain at home and supported holistically To coordinate additional care from other agencies as and when required To arrange and attend the clinical meetings, safeguarding meetings and support meetings To keep accurate and up to date computerised clinical records To work with patients/families/carers on care planning including end-of-life care To ensure patients in specific cohorts have regular health checks including memory screening and Dementia reviews To proactively engage with patients following hospital discharge or A&E admissions to prevent re-occurrence To manage a caseload of patients which are referred in from patients themselves, families, and other services To work towards undertaking overarching health and social care patient assessments as deemed appropriate To make referrals or signpost to statutory and voluntary services To complete all mandatory training and attend other training as required Support clinicians with the admin burden of care home ward rounds to include referrals to District Nursing team and other outside agencies, long-term condition pathways and SMR scheduling.
General Responsibilities for all staff Adhere to practice policies and procedures and relevant legislation including the requirements of any professional bodies. Attend mandatory training as identified by the practice Highlight potential development areas.