JOB TITLE: Care Coordinator REPORTS TO: Care Coordinator Team Leader Job Summary: Care coordinators work closely with the GPs and other professionals within the PCN to identify and manage the needs of the patient, making sure that appropriate support is made available to them, and ensuring that their changing needs are addressed. They focus delivery of the Comprehensive Model for Personalised Care to reflect local priorities, health inequalities or population health management risk stratification. Duties and responsibilities: To work closely with the GPs to support them to provide personalised care to their patient population. To be an accessible point of contact for patients and other health care professionals and to liaise with the GP on their behalf to facilitate efficient personalised care. Help people to manage their needs through answering queries, supporting them to make and manage necessary appointments with community and secondary care, ensuring appropriate follow up, and support with the referral process and ensuring that people have good quality written or verbal information to help them make informed choices about their care. Support GPs to ensure appropriate follow up, post discharge planning and onward referral to community services as appropriate (SPLW, Frailty, Community Rehab, Pharmacists etc.) Support patients to access self-management, peer support and interventions that support them in their health and wellbeing and increase their activation. Help patients to build knowledge and skills to better manage their own Health and Wellbeing. Personal: Maintain good working relationships Take reasonable care of own safety and that of other persons who may be affected by their act or omission. Co-operate with the practice team members to adhere to statutory regulations/policies, codes of practice and safety rules. Confidentiality: In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately In the performance of the duties outlined in this Job Description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the practice as a business organisation. All such information from any source is to be regarded as strictly confidential Information relating to patients, carers, colleagues, other healthcare workers or the business of the practice may only be divulged to authorised persons in accordance with the practice policies and procedures relating to confidentiality and the protection of personal and sensitive data. Health & Safety: The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the practice Health & Safety Policy, to include: Using personal security systems within the workplace according to practice guidelines Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks Making effective use of training to update knowledge and skills Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards Reporting potential risks identified. Equality and Diversity: The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include: Acting in a way that recognizes the importance of peoples rights, interpreting them in a way that is consistent with practice procedures and policies, and current legislation Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues Behaving in a manner which is welcoming to and of the individual, is non-judgmental and respects their circumstances, feelings priorities and rights. Personal/Professional Development: The post-holder will participate in any training programme implemented by the practice as part of this employment, such training to include: Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work. Quality: The post-holder will strive to maintain quality within the practice, and will: Alert other team members to issues of quality and risk Assess own performance and take accountability for own actions, either directly or under supervision Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance Work effectively with individuals in other agencies to meet patients needs Effectively manage own time, workload and resources. Communication: The post-holder should recognise the importance of effective communication within the team and will strive to: Communicate effectively with other team members Communicate effectively with patients and carers Recognise peoples needs for alternative methods of communication and respond accordingly. Contribution to the Implementation of Services: The post-holder will: Apply practice policies, standards and guidance Discuss with other members of the team how the policies, standards and guidelines will affect own work Participate in audit where appropriate.