Pro-active Care Co-ordinator

The Care Coordinator role is seen as a critical and evolving post to support [the Enhanced Health in Care Homes (EHCH) Multi-Disciplinary Teams within the locality to deliver effective, coordinated care for vulnerable and frail adults, particularly those at high risk of a hospital emergency admission, ED attendances or out of hours care.

To proactively coordinate personalised care and support planning for the most vulnerable people in the community, focussing on the frail/elderly and those with other long-term health conditions.

To meet with people, families and carers (in the practice, in their home and in other community settings) to co-ordinate their care, review their needs and help them access the services and support they require, assisting them to understand and manage their own health and wellbeing referring to other professionals where appropriate.

Act as a central point of contact to ensure that patients receive the best possible care, and the person is supported to achieve the outcomes that are important to them. This is achieved by bringing together all the information about a persons 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., Support the PCN in bringing 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 patient. This may include having a caseload of patients.

Support the PCN in improving overall patient care through promotion of services available to them locally within the PCN and the wider health system

Support the frailty team in identifying appropriate patient cohorts for targeted intervention

Partake in multidisciplinary meetings across local care organisations identifying patients in need of review and collating any information required to facilitate their review prior to the meeting.

Provide admin support to multidisciplinary meetings including taking minutes.

Liaise with other key stakeholders as needed for the collective benefit of the patient including but not limited to GPs, nurses, pharmacists, and other support staff from within the PCN practices or from other provider organisations

Undertake delegated clinical procedures within own skills and competence when required (depending on experience and qualifications)

Assist patients and carers in managing their own needs, answering their queries, and supporting them to address their needs

LS25/26 PCN has a patient population of approximately 77,500 across 7 practices. We aim to provide high quality services adhering to principles of best practice, promoting equal opportunities, and working positively with diversity.