Coordinator (Health & Social Care)

The role will involve working closely with team members, GP practices, clinicians, patients, their carers and other services under the leadership of the Frailty Team Lead and duties will include but are not limited to: Care Co-ordination Working with colleagues, use risk stratification tools to identify high-risk patients and ensure they receive a care planning consultation with their GP. Act as the first port of call for service users/patients, in their caseload in relation to their care. Liaise with colleagues in relation to identified needs (including urgent needs). Checking though all hospital discharges and ensuring care review occurs where appropriate. Social care needs identified to make necessary referrals and ensure patient gets support identified in care plan. Monitor referrals to ensure tasks are completed and care delivered by keeping in regular telephone contact. Direct liaison with multi agencies to coordinate care for patients. Make social prescribing referrals to patients identified as potentially benefitting from this service. Contact other teams within the integrated care programme e.g. social services, on behalf of our clinical team with the necessary follow up action to ensure care is allocated to the patient. Work with GP surgeries to identify patients for step up to the service. To be present at integrated team huddles and reflective learning sessions. To support prototyping patient/carer contact roles, and collate patient and carer feedback on their experiences. Maintain and develop engagement with all practice staff and encourage best practice. It is an exciting step towards our ambition of providing integrated care (across healthcare, social care and wider public services) for all our service users and patients in Harrow. Care Planning Record, action and follow up referrals and care packages agreed for all patients that have been care planned, especially those discussed at internal MDT meetings and practice touch points. For a defined caseload of patients ensure that the actions set out in care plans are followed up, and that actions from different professionals, within or outside the Enhanced Frailty Service, are co-ordinated around individual person needs. Working with clinicians, service users/patients, their families and carers, to co-design and deliver care plans and to ensure that the actions set out in care plans are being followed-up and evaluated and are co-ordinated around service user needs. Social Care The Coordinator will be expected to contribute to our work to further develop the role, and to maximise the contribution to care. The Coordinators day to day work will assist the team in evaluating this role and adapting it in the light of experience received from team members, service users, local providers and commissioners. It is important to make certain that our most vulnerable patients receive the co-ordinated care they depend on, care which is responsive to their needs and designed in cooperation with patients, carers and all supporting services. Identifying vulnerable patients that require an integrated care team approach Ensuring individual care plans remain up to date, and that they are monitored and revised following key events such as improvements in health and wellbeing, or following deterioration of their condition, hospital admission or discharge, or service user/patient/carer concerns. Display a detailed knowledge of local statutory and non-statutory support services that could be deployed to assist individuals to achieve optimum health and social care; establish excellent networking skills to co-ordinate effective and responsive packages of care for service users. Ensure good communication is maintained with hospital colleagues, community health and social services to ensure appropriate support is provided to patients upon discharge. Continue the programme for forming links with other providers. Corporate responsibilities 1.Provide cover to other team members as required for annual leave, sickness and training, etc. 2.Identify, report and/or process any issues of concern relating to safeguarding and quality of care arising from working with patients and referring onwards as appropriate. 3.Participate in the induction and training of new members of staff and contribute to WSIC development. 4.Act as an ambassador for the Enhanced Frailty Service. This job description aims to assist the jobholder to know what his/her main duties are. It may be amended from time to time without change to the level of responsibility appropriate to the grade of the post.

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