Care Coordinator

Care Coordinators provide extra time, capacity, and expertise to support patients in preparing for or in following-up clinical conversations they have with primary care professionals. They will support the Clinical directors in coordinating all key activity including improving access to services, providing advice and information and ensuring health and care planning is timely, efficient and patient centered. They will work closely and in partnership with the Social Prescribing Link Workers and support delivery of the comprehensive model of care to reflect local priorities, health inequalities or population health management. Care coordinators will: 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 roles. Work alongside the Health & Wellbeing coaches to identify patients that require additional one-to-one support particularly with mental health issues and provide this support. Liaise with Mind Support workers, GPs and Social Prescribing Link Workers to identify patients that would benefit from one-to-one support and provide this using the available decision support aids. Feedback appropriate patient information to Place Based Teams to ensure all services can support the timely care of the patient. Help people to manage their needs and supporting them to make appointments Raise awareness of shared decision making and decision support tools and assist people to be more prepared to have a shared decision-making conversation. Ensure people have good quality information to help the make choices about their care. Support people to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and wellbeing, including through use of the Patient Activation Measure. Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing. Support the coordination and delivery of MDTs within PCNs. Collation of agendas, production of minutes / action logs for PCN / MDT meetings and ensure all actions are completed including follow up if necessary. Collation and management of shared documents on the appropriate platform ensuring the latest versions are available and is made available in a timely manner. Specific project work liaising with practice leads on implementation of shared process, and collaboration opportunities to support improved patient care.

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