Care Co-ordinator

at  Eltham Medical Practice

Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes. Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care. Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN. Support the coordination and delivery of multidisciplinary teams with the PCN.
Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations. Work with people, their families, carers and healthcare team members to encourage effective help-seeking behaviours. Support PCNs in developing communication channels between GPs, people and their families and carers and other agencies. Conduct follow-ups on communications from out of hospital and in-patient services.
Maintain records of referrals and interventions to enable monitoring and evaluation of the service. Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the persons circumstances. Contribute to risk and impact assessments, monitoring and evaluations of the service Work with commissioners, integrated locality teams and other agencies to support and further develop the role

Please refer the Job description for details