1. Job Role and Purpose: Care Co-ordinators 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 Primary Care Network (PCN) 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. They will focus delivery of the comprehensive model to reflect local priorities, health inequalities or population health management risk stratification. 2. Key Duties and Responsibilities: Care co-ordinators will: Proactively identify and work with a cohort of patients to support their personalised care requirements, using the available decision support aids. Bring together all of a persons identified care and support needs and explore their options to meet these into a single personalised care and support plan (PCSP) based on what matters to the person, ensuring dignity, choice, respect, independence and rights are upheld at all times. Help people to manage their needs, answering their queries and supporting them to make appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care. Identify barriers to or issues preventing greater engagement and/or uptake by patients actively participate in developing solutions for patients and service providers. Raise awareness of shared decision making and decision support tools and assist people to be more prepared to have a shared decision-making conversation. Ensure that people have good quality information to help them make choices about their care, eg. Support people to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and wellbeing, including through use of the Patient Activation Measure. Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing. Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care professionals. Support the coordination and delivery of Multi-Disciplinary Teams within practice. Monitor patients in vulnerable patient groups who fail to attend appointments. Have a clinic that can be booked into to see relevant patients to listen to them, support and signpost them. Identify and work with patients and high impact frequent users to improve continuity of care and personalised care plans. Contact new cancer patients and recently bereaved patient's to offer support. Understand inequalities, inclusivity and the 9 protected characteristics. Any other duties as requested by your line manager. 3. Other Responsibilities Health and Safety To comply with the Health and Safety at Work etc. Act 1974. To take responsibility for their own health and safety and that of other persons who may be affected by their own acts or omissions. Equality and Diversity To carry out at all times their responsibilities in line with Equal Opportunities Policy and Procedure. Risk Management and Clinical Governance To work within the Clinical Governance Framework of the practice, incorporating Risk Management and all other quality initiatives and all aspects of CQC implementation. Confidentiality To maintain confidentiality of information relating to patients, clients, staff and other users of the services in accordance with the General Data Protection Regulations 2018 including outside of the work environment. Any breach of confidentiality may render an individual liable for dismissal and/or prosecution. Safeguarding Whilst in post, staff are expected to acquire and update their knowledge on safeguarding. Professional development The post holder will participate in any training programme implemented by the practice as part of this employment To participate in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development Please Note This job description is intended as a guide to the duties and responsibilities of the post and should not regarded as a complete list of those required to fulfilled under the written statement of the main terms and conditions of employment All job descriptions are subject to review. Post holders are expected to be flexible and be prepared to carry out similar or related duties which do not fall within this job description. This is the job description of the job at present. It is seen this will change and evolve as the Care Coordinator is further developed.