Care Coordinator

at  Nexus Health Group

Working with Patients Work with individual patients, their families, and carers, using a holistic approach, to identify their goals for care, and agree on personalized care and support plans for their care. Support the delivery of these care plans by co-coordinating input from a range of different professionals and services, and helping patients and their carers/families to navigate across health and social care services. Work as part of the primary care team, coordinating care between GPs, practice nurses, clinical pharmacists, social prescribing link workers, and health coaches. Help patients manage their needs by answering queries, being the first point of contact in the practice, and making and managing appointments.
Support patients to utilize decision aids in preparation for a shared decision-making conversation and ensure that they, and their carers/family, have access to good quality written and verbal information to help them make choices about their care. Support patients to take up training and employment where appropriate, and to access benefits where eligible. Help patients to access personal health budgets where appropriate. Make use of tools such as Patient Activation Measure when engaging with patients.
Help patients to access self-management education courses, peer support, or other interventions that support them in improving their health and well-being. Undertake regular reviews of the personalized care and support plans developed with patients. Work in line with national best practices when developing personalized care and support plans. Work with patients over the phone, in person in the practice, or for those who are housebound where necessary to carry out home visits.
Administration Use practice-level reports identifying suitable cohorts of patients to deliver personalized care. Provide accurate and timely data to support audit and monitoring of the service, and any data returns as required by the PCN. Keep accurate and up-to-date records of contacts with patients and their carers/ families in the patients GP record and in their care plan. Follow-up documentation is required for care planning from other organizations, making use of Local Care Records where useful.
Ensure that a proper handover of care between different settings has taken place, including mutual transfer of all organizations communications and patient notes and ensuring care packages are set up. Collect data on patients/carers for recognized outcome measures and document for service interpretation. Managing any necessary meetings to support care planning, identifying patients for discussion, organizing the meeting, and circulating required information beforehand as necessary. Ensure that meeting actions are recorded, disseminated, and followed up in a timely way; so relevant practitioners are aware of meeting decisions and actions/outcomes and chase for action resolution and update.
Network and develop strong relationships with key organizations involved in the patients care planning. Training & Development As this is a new role, training and support will be provided by the Primary Care Network. The care coordinators will be encouraged to form an action learning set across the network and will be given protected time for induction, training, and personal development. Clinical supervision and leadership will be provided within each practice, on a day-to-day basis, and across the network, as a regular meeting/training session.
As part of their personal development, the post holder will be required to undertake appropriate training as set out by the Personalised Care Institute https://www.england.nhs.uk/personalisedcare/supporting-health-and-care-staff-to-deliver-personalised-care/ In order to evaluate the impact of the role and develop it further, there will be a review across the network, led by the network leadership, and the post holder will be required to contribute with their feedback and provision of practice level data, as needed

Please refer the Job description for details