[ref. q63685900] Care Co-ordinator

Care Co-Ordinators will: Work closely with practice and PCN healthcare roles, the Care Coordinator is to identify and work with a cohort of people to support their personalised care requirements, using any available decision support tools such as Patient Activation Measure (PAM), templates and software Collate all of a patients identified care and support needs and review the options to meet these needs and bring them into a single personalised care and support plan (PCSP) in line with best practice Meet patients, patient carers and family members to discuss their personalised care requirements, the services available to them and the help they want Visit patients, checking on the care that they have received and documenting it accordingly Work with the care team to evaluate interventions and identify where and when further ones will be required Help people to manage their needs by answering their queries and supporting them in making appointments Assist patients to be better prepared to have conversations on shared decision making and to improve awareness of shared decision making and related support tools Provide patients with high quality, easy to understand information to assist them in making choices about their care Support patients in understanding their level of knowledge, skills and confidence (known as activation level) when participating in their health and well-being using, where appropriate Liaise with other Care Coordinators in other practices across the area and share best practice Assist patients to access self-management education courses, peer support or interventions that support them in their health and well-being Where appropriate, to assist patients to access personal health budgets Provide coordination and navigation of patients, and where appropriate their carers, across health and social care services, where appropriate working hand in hand with social prescribing link workers (SPLW) Support in the delivery of enhanced services and other service requirements on behalf of the PCN Actively participate in the delivery of multi-disciplinary team (MDT) meetings within PCNs; responsible for preparatory admin, sending meeting invitations and taking notes of meetings.

Engage with and support the new and evolving agendas and service requirements across the PCN, including our work with Care Homes residents and the need to proactively manage their care in an individualised way.