Cross Gates PCN Care Coordinator
Utilise GP Practice clinical systems SystmOne and EMIS and population health data to proactively identify relevant cohorts of patients to deliver personalised care Support patients within these cohorts to access health checks and other health services Support the PCN in improving overall patient care through promotion of services available to them locally within the PCN and the wider health system Liaise with other key stakeholders as needed for the collective benefit of the patient including but not limited to GPs, nurses, pharmacists and other support staff from within the PCN practices or from other provider organisations Communicate effectively and sensitively using language appropriate to the patient and their carer and their level of understanding Raise awareness of shared decision making and decision support tools, and assist patients to be more prepared for shared decision making conversations To provide coordination and navigation for patients and their carers across health and social care services, where appropriate linking with social prescribers and other patient link workers in the PCN Work in partnership with key providers in the local community to enable improved access to services for patients Work with practices to support delivery of any national and local targets outlined in the GP contract Contacting patients to increase uptake in designated clinics such as vaccinations, cancer screening and health reviews.
Identifying reasonable adjustments that can be made for vulnerable groups of patients, to provide a more suitable environment to deliver their care. Coordinating case load visits for reviews or vaccinations to support the clinical team. Undertake quality improvement audits to identify best practice or areas to improve and share learning across the PCN.Participate in PCN workshops/training sessions relevant to the Care Coordinator role.