Care Co-ordinator - Oldham, United Kingdom - Greenbank Medical Practice

Description

The Care Coordinators will play an important role within the practice to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.

The Care Coordinator will potentially provide extra time, capacity, and expertise to support patients in preparing for or in following-up clinical conversations they have with primary care professionals.

They will work closely with the GPs and other primary care professionals within the practice to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers, and ensuring that 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.

• A major part of the role will be promoting the uptake of immunisations and vaccinations to patients within the host practice. Checking patients have received an appointment with the practice and follow up as required.
• Supporting the practice to achieve Quality Outcomes Framework (QOF) indicators.
• Supporting the PCN to achieve indicators for the PCN Network DES.
• Support the practice to improve local uptake of National Immunisation and Vaccination

Programmes and national cancer screening programmes, understanding practice data for uptake and how to tackle health inequalities, supporting peer to peer learning events, and engagement with local providers and with the local community/ PCN.

• Support the improvement in the uptake of the national screening and immunisation programmes through engagement with the local population and partner organisations to promote the importance of attending appointments and where they can access further support.
• Create a system of checks to monitor uptake of vaccines.
• Closely liaise with the practice lead, and the immunisation and vaccination care coordinators within the PCN.
• Supporting practices to incorporate use of Arden's templates and standardised coding to maintain accurate registers.
• Act as point of contact for local hospice and liaising with hospice as required to ensure care planning in place.
• Support practice staff in the upkeep of palliative care registers.
• Link in with and build relationships with the wider PCN team, Social Prescribers, Pharmacists and other clinical/nonclinical partners involved in the patients care.

• Working closely with immunisation and vaccinations care coordinators to support integration of care across organisational boundaries
• A major part of the role will be safety netting and checking that patients referred with a suspected diagnosis of cancer have received an appointment with secondary care in an appropriate timeframe.
• Ensuring that Cancer Care Reviews have been undertaken with all patients within 12 months of diagnosis.
• Improving referral processes for suspected cancers, with a focus on safety netting, ensuring that all patients receive information of their referral, including why they are being referred, the importance of attending appointments and where they can access further support.
• Single point of contact for patients during their cancer journey, or their relatives, to answer questions and deal with problems that arise, linking in or signposting to services such as the hospital team, district nursing or Macmillan services, benefits agency as appropriate.
• Create a system of checks to ensure the patients on suspected cancer pathways are seen in time appropriate manner by secondary care.
• Review patients and follow up each patient for a period of time after a cancer diagnosis, covering topics such as benefits, support groups, offering support to relatives.
• Closely liaise with the PCN lead for cancer, the practice clinical lead, cancer champions and cancer care coordinators within the PCN.
• Be a point of contact for people living beyond cancer, or bereaved relatives, who need support, signpost to support groups available locally or nationally as appropriate.
• Holistically bring together all of a person's identified care and support needs and explore options to help them achieve their needs.
• Working closely with secondary care Cancer Care Coordinators to support integration of care across organisational boundaries.
• Recall of patients with long term conditions
• Invitation and promoting the uptake of post natal checks in a timely manner.