Care Coordinator

The Care Coordinator will be enrolled in, undertaking or qualified from appropriate training as set out by the Personalised Care Institute and works closely and in partnership with the Social Prescribing Link Worker, social prescribing service provider and Health and Wellbeing Coach The Care Coordinator will receive, assist, and direct patients in accessing the appropriate service or healthcare professional in a courteous, efficient and effective way. To support the practices delivery of excellent healthcare by supporting annual recalls and health campaigns, ensuring that patients feel a co-ordinated approach to their healthcare provided by West Meon Surgery. Job Responsibilities Increase take-up of cancer screening initiatives including bowel, breast and cervical, and improve the quality and timeliness of referrals under the two week wait. Improve patient engagement with annual health checks and condition specific follow up within primary care. Help to raise awareness of health and well-being, screening, annual health checks and reviews for long term conditions and how it can be promoted. Provide co-ordination and navigation through the health and care systems. Make referrals to services and other health and care professionals. Help patients prepare for/follow-up. Signpost patients to information Work in partnership with MDT colleagues including social prescribing link worker(s) and health and wellbeing coach(es) Undertake scanning of clinical documents (such as clinic reports, 111 reports, and out of hours information) are filed onto the Docman system and coded accordingly. Ensure an effective and efficient reception service is provided to patients and any other visitors to the Practice. Deal with all general enquiries, explain procedures and make new and follow-up appointments. Receive and make telephone calls as required. Divert calls and take messages, ensuring accuracy of detail and prompt appropriate delivery. Enter requests for appointments or home visits on to the system, ensuring careful recording of all relevant details and where necessary refer to Duty Doctor. Advise patients of relevant charges for private (non-General Medical Services) services, accept payment and issue receipts for same. Ensure that all new patients are registered onto the computer system promptly and accurately. Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care Support patients to utilise decision aids in preparation for a shared decision-making conversation Holistically bring together all of a patients identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person Help patients to manage their needs through answering queries, making and managing appointments, and ensuring that patients have good quality written or verbal information to help them make choices about their care, using tools to understand patients level of knowledge, confidence in skills in managing their own health Support patients to take up training and employment, and to access appropriate benefits where eligible for example, through referral to social prescribing link workers Assist patients to access self-management education courses, peer support or interventions that support them to take more control of their health and wellbeing Explore and assist patients to access personal health budgets where appropriate; Provide coordination and navigation for patients and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; and Other job responsibilities 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 patients back to other health professionals within the PCN Raise awareness within the PCN of shared decision-making and decision support tools 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 Have basic safeguarding processes in place for vulnerable individuals Provide opportunities for the patient to develop friendships and a sense of belonging, as well as to build knowledge, skills and confidence. Discuss patient related concerns and be supported to follow appropriate safeguarding procedures (e.g. abuse, domestic violence and support with mental health) with a relevant GP.

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