Job Title: Care Coordinator
Responsibilities:
1. Work closely with practice and PCN healthcare roles to identify and support a cohort of people with personalized care requirements, including patients discharged from health or social care settings.
2. Collate identified patients and support needs into a single personalized care and support plan.
3. Use primary care software to coordinate recall lists for patients being monitored for chronic health conditions.
4. Proactively case find using population health intelligence data.
5. Help people manage their needs by answering queries, supporting appointment scheduling, and providing quality written or verbal information.
6. Monitor all referrals, missed appointments, and investigations, including cancer 2ww referrals and missed follow-up appointments.
7. Record patients' demographic and simple health information as part of their personalized care plan/record.
8. Work closely with other social and health care professionals.
9. Signpost patients to SPLW to access appropriate benefits and employment/training opportunities.
10. Assist patients in preparing for shared decision-making conversations and improve awareness of related support tools.
11. Provide patients with high-quality, easy-to-understand information to assist them in making choices about their care.
12. Liaise with other Care Coordinators in different practices within the PCN to share best practices.
13. Assist patients in accessing self-management education courses, peer support, or interventions that enhance their health and well-being.
14. Provide coordination and navigation for patients and their carers across health and social care services, collaborating with social prescribing link workers (SPLW) and cancer care coordinators.
15. Support the delivery of enhanced services and other service requirements on behalf of the PCN.
16. Participate in the delivery of multi-disciplinary teams (MDT) within PCNs.
17. Undertake all mandatory training and induction programs.
18. Contribute to clinical governance and embrace its spectrum.
19. Develop personally and professionally through participation in training and service redesign activities.
20. Attend formal appraisals with their manager at least every 12 months to review performance and training objectives.
21. Contribute to public health campaigns (e.g., flu/covid clinics) through advice or direct care.
22. Maintain a clean, tidy, and effective working area at all times.
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