Care Coordinator - Eastbourne, United Kingdom - South Downs Health and Care

Description

Care coordinators play an important role within a Primary Care Network (PCN), of local GP Practices, to proactively identify and work with people, including the frail/elderly and those with long-term health conditions, to provide coordination and navigation of care and support across health and care services.

They work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed.

This is achieved by bringing together all the information about a person's identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.

Care coordinators review patients' needs and help them access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers, health and wellbeing coaches, and other professionals where appropriate.

Care coordinators could potentially provide time, capacity, and expertise to support people in preparing for or following-up clinical conversations they have with primary care professionals to enable them to be actively involved in managing their care and supported to make choices that are right for them.

Their aim is to help people improve their quality of life.

A Care coordinator will be a caring, dedicated, reliable, person-focused and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills.

They will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing people, their families, and carers with high quality support.

This role is intended to become an integral part of the PCN's multidisciplinary team, working alongside social prescribing link workers and health and wellbeing coaches to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN.

Please note that the role of a care coordinator is not a clinical role.

SDHC is a GP Federation and as such, we're a company rather than a GP practice, although our work mainly involves delivering NHS contracts on behalf of our members and the ICB.

Our members/shareholders are our local 17 GP practices covering Eastbourne, Hailsham and Seaford with a population of approximately 200,000 patients.

Our main purpose is to support GP practices in their task of providing patient care by enabling them to provide and invest in sustainable services by reducing the burden of their workload, maximising income opportunities and minimising their risks and liabilities.

We ultimately aim to improve patient experience and outcomes in a sustainable way.

We encourage our staff to take ownership and responsibility, to highlight concerns and feedback and to make an active contribution to their individual success as well as that of their team and the wider organisation.

We operate a no-blame culture; by this we mean that everyone is held accountable but, in an environment, where the focus is on the learning that can be adopted and shared from instances where things haven't gone so well.

We offer a trust-based workplace where we appreciate that teams are often best placed to contribute to building and improving working practices, while still having regard to our business model and the needs of our direct customers - GP practices - so that we can continue to make a difference to patients as the service users.

Delivery

The Care Coordinator responsibilities include but are not limited to the following:

• Undertake work to support DES requirements or other work that directly benefits GP practice workloads in line with PCN directed priorities. Achieving targets for work agreed with PCN and Care Coordinator team.
• Accept referrals from GP practice staff and SDHC employed staff supporting the PCN following triage by the care coordination lead/team.
• Work with GPs and other primary care professionals within the PCN to identify and manage a caseload of patients to support their personalised care requirements, using available decision support aids as appropriate
• Once referrals are accepted, manage patients within the service specification KPIs, discharging patients within 12 weeks of first contact.
• Where appropriate provide a written discharge summary to the patient and referrer at the time of, or within a week from, discharge.
• Where appropriate work with patients to create meaningful written care plans, using SDHC/PCN agreed templates.
• Work closely and in partnership with the Social Prescribing Link Worker, Health and Wellbeing Coaches and Pharmacy teams to ensure that patients access help from the most appropriate service. Sh