The Care Co-ordinator will:
Utilise population health intelligence to proactively work with the MDT to ensure they are aware and notified of patients that would benefit from access to personalised care. Work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the PCN. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations. Bring together all of a person's identified care and support needs from digital information, and explore options to meet these into a single personalised care and support plan, using excellent communication and organisational skills to liaise with other stakeholders as needed for the collective benefit of the patients.
Help people to manage their needs through answering queries, signposting to relevant services and ensuring that people have good quality written or verbal information to help them make choices about their care. Identify patient need and assist to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level. Signpost people to gain access for personal health budgets where appropriate. Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches and other primary care professionals.
Ensure awareness of and basic safeguarding processes are in place for vulnerable individuals. Communication and Interpersonal skills communicate effectively across a wide range of channels and with a wide range of individuals, the public, health and social care professionals, and colleagues maintaining the focus of communication on delivering and improving health and care services. Demonstrate inter-personal skills that promote clarity, compassion, empathy, respect and trust. Ensure all patient related information is treated sensitively and adhere to the principles of confidentiality at all times.
Report any accidents or incidents and raise any concerns as per organisational policy. Ensure clear, concise, accurate and legible records and all communication is maintained in relation to care delivered adhering to local and national guidance. Attend and contribute to meetings within the Network as required.
Care Co-ordinator Responsibilities:
Ensure all mandatory training is completed on an annual basis including; safeguarding, confidentiality, equality and diversity, Cardio-pulmonary resuscitation etc. Ensure infection control guidelines are maintained. Work with a supervisor to take responsibility for developing own practical and theoretical competence, developing own reflective practice skills. Contribute towards developing a culture of continued learning and innovation, supporting continuous improvements in care delivery. Adhere to legislation, policies, procedures and guidelines both local and national, regularly attending workplace and staff engagement meetings.
Maintain accurate and contemporaneous patient health records. Work in an effective and organised manner demonstrating excellent time management and organisational skills to effectively deliver person-centred care for an allocated group of individuals.
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 may be required to travel independently between practice sites and to attend meetings etc. hosted by other agencies.
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