Job Summary The Care Coordinator role plays a pivotal part in improving the quality of seamless coordinated care across the Primary Care Network (PCN), that enables Multi-Disciplinary Teams (MDT) to advance in their ways of working and ultimately contributes to the effectiveness of patient care provided. As a Care Coordinator the job holder will work closely with the practices and the MDT, as a pivotal role for ensuring all patients across the locality receive the best possible care and service. This role will support the Clinical Director and other key stakeholders in coordinating all activity including access to services, advice, and information, and ensuring health and care planning is timely, efficient and patient-centred. This will involve coordinating the work of healthcare professionals and non-clinical staff including volunteers involved in the care of patients registered at GP practices within the wider PCN population. A large proportion of this role will be focused on the Enhanced Health in Care Homes MDT: improving the current level of primary medical care by moving away from traditional reactive models of care delivery towards proactive care that is centred on the needs of individual residents, their families and care home staff. Such care can only be achieved through a whole-system, collaborative approach. The care coordinator will support the MDT with the weekly virtual home round through identification of people in need of review, or collation of information on people requiring an MDT review in addition to providing coordination, secretarial and administrative support to the MDTs.. Primary Duties and Areas of Responsibility Multi-Disciplinary Teams Overall responsibility for arranging the weekly PCN led MDT meetings (including the weekly virtual Care Home(s) MDT) and the smooth running of integrated care within the team setting. The key role of the Care Coordinator will be to schedule the weekly MDT meetings in conjunction with the Health and Social Care Coordinator and in liaison with Clinical Lead as necessary, manage the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members in advance of the meeting. Coordinate and manage the administrative functions of MDT meetings. Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function. Take minutes of MDT meetings and disseminate; chase progress against actions identified in these meetings and ensure follow up where necessary. Manage reporting required and associated within the DES specifications for required services. Patient Identification Receive and collate information from transfers of care (including hospital admissions and discharges) plus out of hours calls and prepare MDT case notes for lead clinician to review before submission to MDT. Liaise with service providers and clinicians to identify frequent flyers, and new service users utilising risk stratification tools provided and present this information to the weekly MDT meetings. Support the completion of new referrals by checking criteria, and where criteria have been met, direct referral to the MDT. Signpost team members, service users and carers to relevant services Maintenance of IT based information systems and responsibility for key performance data: Ensure accurate notes are transcribed into relevant practice clinical systems (EMIS) for each patient during the MDT, or within 3 hours after, to ensure patient records are up to date and all clinicians can access correct information To ensure the IT requirements for recording activity are adhered to in collaboration with other team members To provide agreed performance/activity data within the MDT and PCN and wider OHP organisation. Communication and collaborative working relationships Demonstrates ability to work as a member of a team. Can recognise personal limitations and refer to more appropriate colleague(s) when necessary. Actively work toward developing and maintaining effective working relationships both within and outside the PCN or group of PCNs. Liaises with other stakeholders as needed for the collective benefit of patients including but not limited to Patients GP, Nurses, other practice staff and other healthcare professionals including pharmacists and pharmacy technicians from provider and commissioning organisations. Work with service users, PCN practices and partners e.g., Care Homes to ensure new referrals are logged and allocated Develop excellent working relationships with all partners, wider service networks including the voluntary sector, GP practices, adult social care, hospitals, community pharmacists and other members of the MDT Acting as a point of contact for residents, families and professionals who visit the care home, such as MDT members and in-reach specialists. Meet regularly with the clinical lead and review case load and MDT function. Keep the MDT and Dover Town PCN organisation abreast of good news stories. Provide background information about individuals for the weekly MDT meetings Communicate effectively with service users and their families/carers, other staff both internal and external and members of the public Manage and prioritise workload daily and deal with the competing demands of the MDT Other responsibilities To always act in an anti-discriminatory manner To be able to plan and respond to workload according to operational priorities To support the delivery of these functions across wider locality areas where necessary To undertake any training required to maintain competency including mandatory training To contribute to, and work within a safe working environment. The Care Coordinator must always carry out duties and responsibilities with due regard to the GP Practices equal opportunity policies and procedures The Care Coordinator is expected to take responsibility for self-development on a continuous basis, undertaking on-the-job training as required The Care Coordinator must be aware of individual responsibilities under the Health and Safety at Work Act, and identify and report as necessary any untoward accident, incident, or potentially hazardous environment. Patient Care Communicate effectively and sensitively and use language appropriate to a patient and carer/relatives condition and level of understanding Effectively use all methods of communication and be aware of and manage barriers to communication Effectively recognise and manage challenging behaviours, carers and or relatives Provide information to patients, their carers and/or relatives on behalf of the team Supporting Care Delivery Be the point of liaison for service users and interface with all health and social care professionals, including keeping everyone informed and updated Follow through actions identified by the MDT including arranging tests, referrals, signposting, etc. Follow through with service users and others involved to ensure all services and care arrangements are in place Autonomy/Scope within Role The post holder will be required to work within clearly defined organisational protocols, policies and procedures Key Relationships Key Working Relationships Internal: Clinical Lead for the MDT GPs and General practice teams within the PCN PCN Clinical Director MDT members including but not exhaustive: Clinical Pharmacists, Pharmacy Technicians, Physician Associates, Physiotherapists, Paramedics, Social Prescribing Link Workers Key Working Relationships External: GPs from neighbouring PCNs PCN staff from neighbouring PCNs, Care coordinators and MDT staff Community Nursing team District Nursing, Frailty team, Community Geriatrician External organisations: Mental Health NHS organisations, local Council, Social Services, Hospices, Voluntary and Independent Sector providers Service providers including Care Home and Residential Home providers Patients/service users Carers/relatives Health and Safety/Risk Management The post-holder must always comply with the organisation and Practices Health and Safety policies, by following agreed safe working procedures and reporting incidents using the organisations Incident Reporting System. The post-holder will comply with the Data Protection Act (1984), The General Data Protection Regulations (2018) and the Access to Health Records Act (1990). The post-holder will comply with all necessary training requirements relevant to the role as identified by the organisation. Equality and Diversity The post-holder must co-operate with all policies and procedures designed to ensure equality of employment. Co-workers, patients and visitors must be treated equally irrespective of gender, ethnic origin, age, disability, sexual orientation, religion etc. Respect for Patient Confidentiality The post-holder should always respect patient confidentiality and not divulge patient information unless sanctioned by the requirements of the role. Special Working Conditions The post-holder is required to travel independently between practice sites (where applicable), and to attend meetings etc. hosted by other agencies. Job Description Agreement This job description is intended as a basic guide to the scope and responsibilities of the post and is not exhaustive. It will be subject to regular review and amendment as necessary in consultation with the post holder.