Care Coordinator - Wingate, United Kingdom - NHS North Of England Commissioning Support Unit

NHS North Of England Commissioning Support Unit
NHS North Of England Commissioning Support Unit
Verified Company
Wingate, United Kingdom

1 week ago

Tom O´Connor

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Tom O´Connor

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Description

In your role you will work as part of the Durham Coast PCN Integrated Care Co-ordination Team and will be aligned to specific practice(s) within the PCN.

You will be responsible for co-ordinating, integrating and delivering support to practices patients within care home setting.

You will ensure patients have good quality information to help them make informed choices about their care by liaising with a broad range of medical, social and third sector services.

You will ensure effective, co-ordinated care is available to these patients, proactively identifying their personalised care needs, using decision support aids as required.


You will bring together the patients identified care/ support needs and explore with them options to meet their needs, recording them in a single personalised care and support plan (PCSP).

You will work with patients, their families and carers, to improve their health and wellbeing by navigating them to the appropriate services.

Ensuring they have good quality information to support their decision making, by taking a holistic approach.

Bringing together all of their identified care and support requirements into a single personalised plan, based on what matters most to the patient.


You will guide them to access these services and any appropriate funding that is available to support them, including access personal health budgets where appropriate.

By using Population Health Intelligence, the service may be targeted at specific patient groups, identified by the GP practices in the PCN.

These patients will include but are not limited to; adults with complex long term health needs, depression and organic mental illness.

You will be responsible to act on the follow up requirements contained in Secondary Care discharge letters, ensuring patients are aware of any additional monitoring or tests that are required and the timescales.


You will liaise with Secondary care clinics, supporting their requests for pre-operative assessments conducted in primary care, this will include engaging with the patient, organising appropriate appointments (within practice clinics or in their own homes) and then ensuring the results are returned to the requesting clinician/service.

You will be working at a variety of venues in general practice and the community, including care homes, utilising premises in agreement with stakeholders and clients.

You will work collaboratively with the general practice teams to meet the needs of patients, alongside social prescribing link workers, to support the delivery of co-ordinated care for the Primary Care Network.

Please see the attached Job Description in Supporting Documents for more information.
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