Coordination Duties Improve the care frail patients receive by coordinating the delivery of their care, proactively identifying unmet care needs and preventing unnecessary hospital admissions. Work with clinical professionals and patients to create care plans for frail patients. Ensure that all patients on the learning disability and dementia register receive an annual review in accordance with protocols. Liaise with the learning disability and dementia lead in each Practice to ensure that timely care is received as needed, clinical records are updated and annual review documents are up to date. Provide coordination support for patients to navigate health care services and expedite referrals, where necessary, to providers such as Proactive care, Care Home Matrons, Wheelchair Services, Community Nurses, Eyes and Ear Tests, SaLT, OT or Physio, Dementia Services. Document end of life in accordance with protocol and attend Practice GSF meetings, linking in with the Echo team, where required. Coordinate annual Structured Medication Reviews, SMR, with lead clinicians and MOCH Pharmacists. Refer to PCN personal care role workers, social prescribers and MIND wellbeing workers, where a patient is identified as potentially benefitting from this service. Support the Practice in achieving its Quality and Outcome Frameworks and other DES or LES specifications. Monitor referrals to ensure tasks are completed and care is delivered by keeping in regular contact with patients and their representatives. Help people to transition seamlessly between services and support them to navigate through the health and care system, liaising directly with multiple agencies to coordinate care for patients. Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes. Review and update personalised care and support plans at regular intervals. Assist with the coordination of annual Flu and Covid vaccines programmes, gaining consent from patients or their representatives as appropriate, running searches to help with planning and entering data on the clinical system. Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities. Work in accordance with the Practices and PCNs policies and procedures. Multidisciplinary Working Support the clinical and social care professionals in coordinating all key activity, including access to services, Multidisciplinary Team meetings, advice and information and ensuring health and care planning is timely, efficient and patient-centred. Support the setting up, coordination and management of regular multidisciplinary hub meetings, including but not limited to, Frailty and Palliative care, to ensure a smooth and coordinated approach, especially where multiple agencies are involved. Develop and coordinate the integrated care team hub, taking responsibility for a caseload of patients. Ensure regular and consistent communication with referrers regarding patient progress and any complications or guidance suggested by the MDT. Work with other Care Coordinators to develop knowledge of local services and teams, supporting and assisting each other through sharing of knowledge and good practice. Maintain and develop engagement with all Practice staff and encourage best practice. Act as a champion for personalised care and shared decision-making within the PCN. Identify opportunities and gaps in the service and contribute to continuous improvements to the service and business planning. Attend bi-weekly proactive care team meetings. Attend the PCN Board meetings, as required, to provide updates on EHiCH work and any other relevant information. Attend Practice meetings, when requested. Care Home Specific Duties Organise a weekly/bi-weekly ward round for each care home, as required by the allocated Practice, to obtain relevant information, such as new hospital attendances, falls, medication and updates regarding residents approaching end of life. Ensure all updated information gathered from the ward round is documented on the patients clinical record. Book appointments for care home residents on the clinical system, as required. Discuss personalised care for care home residents with patients, their families and the care home staff, ensuring the personalised care and support plans are recorded on the clinical system and the relevant template is completed. Gather appropriate information to record on ReSPECT forms. Discuss the hospital discharges for care home residents with patients, their relatives and the care home, as appropriate, ensuring the care plan is updated. Align the collection of new patient data/new patient checks with the requirements of the care home sector, using the new Care Home Patient Form, ensuring all information is entered onto the clinical system. Organise monthly care homes education meetings to discuss key topics including, but not limited to, ReSPECT Forms, Proxy Access, New Care Home Resident forms, Covid or flu vaccinations and consent. Coordinate annual structured Medication reviews with Care Home Matrons. Carry out any of the above coordinator duties in relation specifically to care home residents. Accountability The above list of duties is not exhaustive and may be subject to change, as deemed necessary.