Care Coordinator - Thornton Cleveleys, United Kingdom - Torentum Primary Care Network

Description

Job Title :
Care Coordinator


Accountable to :
Torentum Primary Care Network


Reports to:
Clinical Director / PCN Manager


Salary:
up to £24,300 pro rata depending on experience


Hours: 37 hours per week (would consider part time)


Job Summary

Care Coordinators play an important role in working with people who have been identified as complex or vulnerable, including the frail/elderly and those with long-term conditions, to provide coordination and navigation across health and care services.

They work closely with GPs and Practice Teams, acting as a central point of contact to ensure appropriate support is made available to the patient and their carers.

This is a non-clinical role requiring strong organisation and communication skills.

Care Coordinators bring together all the information about a patient's care and support needs and help to create a personalised care and support plan based on what matters to the patient.

They help patients to access services, managing referrals in to the PCN Wellbeing Hub.

A key responsibility of the role is to provide strong administration support to PCN meetings, managing calendar appointments, minuting meetings, chasing up actions etc.

This includes the weekly Care Home meetings, where the Care Coordinator will act as the liaison between MDT members and Care Home staff.

Primary Care Networks

A Primary Care Network (PCN) enables the provision of proactive, accessible, co-ordinated and integrated primary and community care, improving outcomes for patients.

They are formed around natural communities based on GP registered lists, serving populations of around 30,000 to 50,000.

The Torentum Primary Care Network was formed in June 2020.

It includes 3 GP Practice's, The Cleveleys Group Practice, The Crescent Surgery and The Thornton Practice, serving a population of approximately 33,300 registered patients.

Primary Duties and Areas of Responsibility

Project Support

• Set up and manage attendance at meetings; minute meetings and take responsibility for following up actions.
• Prepare and present data from emis, or other sources e.g. Fingertips/Aristotle to support decisions being made in projects.

Direct patient facing work

• Work collaboratively with staff across the PCN to proactively identify and support patients; working with those patients, their families and carers, to provide coordination and navigation across health and care services.
• Holistically bring together all of a person's identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), based on what matters to the person. This will be done in liaison with clincial staff and Social Prescriber Link Workers who can advise on community services.
• Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care.
• Receive and collate information from transfers of care (including hospital admissions and discharges), out of hours calls, DNARs etc and follow up with the patient to identify their needs.

Care Home Multi-Disciplinary Teams

• Administer the weekly Care Home MDT meetings; managing the meeting agenda, supporting the Chair, taking minutes, dealing with follow up actions, ensuring that all new referrals are identified, and information circulated to team members in advance of the meeting.
• Act as a point of contact for residents, families, carers and professionals who visit the care home, such as MDT members and inreach specialists. Communicate effectively and sensitively and use language appropriate to a patient and carer/relative's condition and level of understanding.
• Following MDT meetings, ensuring that Personalised Care and Support Plans and EPaCCs are completed for all patients in Care Homes; working with clinical staff to create new plans and update plans as patient needs change.
• Receive and collate information from transfers of care (including hospital admissions and discharges), out of hours calls etc, for Care Home patients, presenting this to the MDT to help identify those needing Care Home Rounds.
• Liaise with service providers and clinicians to identify service users (utilising the risk stratification tools provided) to present this information to the weekly MDT meetings.
• Support the completion of new referrals by checking criteria, and where criteria have been met, referring to the MDT.

Collaborative working relationships

• Collaboratively work with other Care Coordintors, managing the workload as a team and covering duties for other Care Coordinator absences.
• Work as a cohesive team with the other staff in the Wellbeng Hub, receiving referrals and identifying which Wellbeing Hub roles could best support the patient.
• Actively work toward developing and maintaining effective working relationships both within and outsi