Care Co-Ordinator Role (ARRS)

You will work with GP Practice teams to coordinate the care of patients with frailty,cancer,long-term conditions,safeguarding and social issues,patients requiring proactive care and patients who require support to communicate effectively. You will liaise with the patient, practice team, secondary care teams, social services, the voluntary and community sector, and other members of the Primary care Network team to help smooth the patient's pathway, expedite care where appropriate, and follow up letters and results. Yo will support the practice to deliver good quality care for frail patients, patients in palliative care and patients with long term conditions . You will work with the practice team to prepare for effective GSF and frailty meetings and ensure that processes such as falls assessments and medication reviews are carried out in a timely manner. Where appropriate, you will help develop a personalised care and support plan for these patients. You will support the practice to ensure that patients are reviewed at an appropriate frequency, and to achieve QOF, IIF, LIS & DES targets. You will be working as part of the Redcar Coastal PCN team to support the patients of 7 GP Practices., Service Delivery

• Working with Practice teams to coordinate care for patients with greater needs to improve the patient pathways and expedite care as appropriate
• Proactively identify patients who require care coordination,using agreed criteria and population health tools as appropriate
• Support the delivery of the practice GSF and frailty programmes
• Support the achievement of practice quality standards including QOF,IIF,DES&LIS
• Work closely and in partnership with the Social Prescribing Link Workers to address wider determinants of health,such as poor housing,debt stress and loneliness and identify and prioritise a person's care/support needs in a single personalised care and support plan,based on what matters to the person in shared decision making process
• Help patients manage their needs through answering queries,making and managing appointments and ensuring that people have access to good quality information about their care
• Coordinate appointments and encourage uptake of vaccinations in eligible populations and assess people to access personal health budgets
• Encouraging uptake of QOF LTC Annual and Structured Medication Reviews
• Encouraging the delivery of good quality annual health checks for patients with Learning Disabilities and SMI
• Supporting the Practice in delivering its IIF priorities
• Supporting cancer screening ,including FIT Tests/bowel screening,cervical screening and breast screening.Refer smokers to smoking cessation
• Coordinating and following up of referrals & appointments
  
  ELM Alliance LTD (Eston, Langbaugh, Middlesbrough Alliance) is a GP Federation, established in 2016; wholly owned by the local GP Practices in Middlesbrough, Redcar and Cleveland. The organisation delivers primary care and community services by contract with the NHS CCG, Local Primary Care Networks and Local Authorities. In addition, we provide enablement and support to our members.
ELM was rated GOOD by the Care Quality Commission in the latest review in 2019. Our ambitions include:
• Delivery of safe and effective services for patients and members.
• Reduce inequalities of healthcare, enable patients to have a longer and healthier life.
• Support and enable our members to deliver its targets and contractual requirements.
• Improve population health and wellbeing through a place based delivery.
• Growing in sustainability and service offer, through caring and well led approaches.