Care Coordinator

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Job Overview:

Care Coordinators work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed. 

This is achieved by bringing together all the information about a person’s identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person. 

Care coordinators, review patients’ needs and help them access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers, health and wellbeing coaches, and other professionals where appropriate. 

Main Duties:

The precise role of each Care Coordinator will vary slightly depending upon their scope (e.g.; Care Homes, End of Life, Early Cancer, etc) but will be made up of many of the following:

• Support clinical and social care professionals in coordinating all key activity including access to services, MDT meetings, advice and information, and ensuring health and care planning is timely, efficient and patient-centred. The above list of duties is not exhaustive and may be subject to change as deemed necessary. 
• Establish, coordinate and manage regular multidisciplinary hub meetings, including, but not limited to; Cancer, Cardiology, Mental Health, Frailty and Palliative care, to ensure a smooth and coordinated approach, especially where multiple agencies are involved.
• Develop and coordinate the integrated care team hub, holding a caseload of patients. 
• Improve the outcomes of patient groups by coordinating the delivery of their care, proactively identifying unmet care needs and preventing unnecessary hospital admissions. Working closely with the PCN and wider multidisciplinary team (MDT).
• Work with other Care Coordinators to develop knowledge of local services and team, supporting and assisting each other through sharing of knowledge and good practice.
• Monitor referrals to ensure tasks are completed and care delivered by keeping in regular contact with all parties.
• Help people transition seamlessly between services and support them to navigate through the health and care system; Direct liaison with multi agencies to coordinate care for patients.
• Refer to PCN social prescribers, health and wellbeing coaches and MIND workers where a patient is identified as potentially benefitting from this service 
• Maintain and develop engagement with all practice staff encouraging ‘best practice’. Act as a champion for personalised care and shared decision making within the PCN; Develop the role of Cancer Champion within practices
• Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers and other primary care roles
• Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the person’s care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes; 
• Review and update personalised care and support plans at regular intervals; 
• Support the coordination and delivery of MDTs within PCNs. 
• Complete training requirements as specified by Personalised Care Institute and/or Sussex training Hub 
• Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner; 

Person Specifications: