COPD Care Coordinator

Job responsibilities

• Complete aspects of COPD assessment and review work, following Service standard operational procedures and processes.
• To include completion of duty screening calls and onward referrals following referrals received by GP/professional.
• Identify and use opportunities to promote healthy lifestyles e.g. diet, exercise.
• Have knowledge and information on local services available to patients whilst considering a range of options during ongoing patient assessments, analysing service users needs.
• Act as advocate and facilitator to resolve issues that may be perceived as barriers to care.
  • Develop a partnership approach to working, in order to empower the patient and carers, in diverse situations/cases.
  • Support people in accessing appropriate information and support, by sign-posting to a range of support services and take an approach which helps people to self-manage where appropriate.
  • Make pre-planned outbound telephone calls to patients to assess on-going needs to enable a proactive prevention approach.
  • To maintain accurate, clear, concise and contemporaneous records as per Trust policy and communicate information to members of the Team as necessary.
  • Liaise and communicate with referrers, patients, relatives, carers, and other health and social care professionals to support and coordinate care.

    Communicate with other members of the multi-disciplinary team

  • Be the interface between patients and/or carers, Primary Care, Community Health and Social Care, ensuring the needs of the patient is incorporated into individual care plans.
  • Deal in a professional, helpful and sensitive manner with patients, service users, staff and other agencies by telephone or face to face, taking messages, advising service users about visits, referring other issues as appropriate and answering routine enquiries.
  • Act as a contact to assist with case management of patients at risk of admission, identifying sources of support in liaison with case managers e.g. Community Matron.
  • prepare andprovide patient information and link with GP practices to help reduce A&E admissions.
    • Coordinate and manage the administrative functions for the integrated Multi-disciplinary Team Meetings. This will include organising and adjusting meetings and tasks on behalf of a number of stakeholders, responding to urgent clinical tasks as required.
    • Be the point of liaison for service users receiving care coordination and interface with all professionals involved in service users care including primary and secondary care, community services, carers and other relevant groups.
    • Requirement to receive telephone calls/correspondence from partnership health professionals, relating to single point of access, where calls are received and triaged. Decisions are based on the individual service criteria as to the route the call will take, with guidance from professionals regarding clinical/non-clinical facts/situations where a suitable course of action needs to be determined.
    • Co-ordinate the handover between other Specialist Nurses to facilitate the safe and effective transition of care between services, in order to provide seamless support for patients, their families and carers.
  • • Liaise with medical and nursing personnel in primary, secondary and specialist centres about patients and service provision related matters including statutory and voluntary providers of care.
    • Take responsibility for the facilitation of regular Multidisciplinary Team Meetings, which involves coordinating and organising partnership professionals. The information in relation to these meetings from a wide range of other strategies/projects is to be collated and delivered prior to the MDT.
    • Devise and maintain efficient filing, clerical and office systems, and provide administrative support, including photocopying, and dealing with other forms as required.

Person Specification

Our Values

Essential

• We are Kind
• We are Open
• We are Inclusive

Qualifications

Essential

• NVQ3 or recognised certificate in office administration or equivalent Qualification / experience
• Evidence of continued role development

Experience

Essential

• Minimum 2 years working within Health and/or Social Care
• Demonstrate IT Literacy across a range of IT and administrative systems / Data management
• Evidence of ability to communicate at all levels across all boundaries
• Experience of supporting Service Improvement
• Experience of working within a multi-Disciplinary setting
• Evidence of dealing with people in highly emotive situations
• Ability to provide confidential administrative support within a complex service

Skills

Essential

• Excellent written & verbal communication skills
• Ability to provide & receive complex information. Ability to motivate & negotiate
• Ability to work independently and as part of a team
• Ability to prioritise own workload between competing demands ...