Coordinate and Integrate Care: Urgent and non-urgent and Care Home Develop an in depth knowledge of the local health and care infrastructure and encourage signposting. Enable patients to access support and services that are right for them. Work towards increasing patients understanding of how to manage and develop health and wellbeing through offering advice and guidance. Work with the wider PCN, MDTs, and the social prescribing service to look at how carers can support people.
Review and update care and support plans at regular intervals. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the patients care, facilitating a coordinated approach, and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported. Actively participate in multidisciplinary team meetings in the PCN as and when appropriate. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.
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