Care Co-ordinator - Ventnor Medical Practice
The Care Coordinator will: Provide personalised support to patients with frailty and specifically care home residents, their families and carers enabling them to take control of their wellbeing and improve their health outcomes. Manage and prioritise their caseload in accordance with the needs, priorities and any urgent support required by individuals on the caseload Work with frail and care home residents and carers to co-produce a simple personalised support plan identifying health and social care needs Provide targeted support and proactive reviews for vulnerable, complex patients and those at risk of admission and re-admission to secondary care Manage a caseload of potentially complex patients and to provide advice for the GP management on the more complex patients Take referrals for individuals or proactively identify people who could benefit from support through care coordination.
You would be required to have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs. Work towards increasing patients understanding of how to manage and develop health and wellbeing through offering advice and guidance.The Care Coordinator will need to develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them alongside work with the wider PCN, MDTs, and the social prescribing service to look at how Carers can support people.
Support people to develop and implement personalised care and support plans whilst reviewing and updating them on regular intervals You will ensure the personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes.