Health Care Coordinator

at  Eden Primary Care Network

Main duties/Key tasks: Undertake comprehensive geriatric assessment and/or annual review on all patients scoring moderate to severe on the practice frailty register Keep care records up to date by identifying and updating missing or out-of-date information about the persons circumstances; Highlight any safety concerns. Maintain records of referrals and interventions to enable monitoring and evaluation of the service; To provide patients with high quality, easy to understand information to assist them in making choices about their care. To take a holistic approach, based on the persons priorities, and the wider determinants of health. To assist patients to be better prepared to have conversations on shared decision making and to improve awareness of shared decision making and related support tools 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. Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support. 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. Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes; Take referrals for individuals or proactively identify people who could benefit from support through care coordination; Explore and assist people to access a personal health budget where appropriate.
Identify unpaid carers and help them access services to support them; Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons 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; Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality diversity and inclusion training and health and safety Work with Team leader for advice and support. Act as a champion for personalised care and shared decision making within the PCN Key Result Areas Actively collect and maintain data that will demonstrate patient improvement in key areas. Ensure delivery of best practice in clinical practice, caseload management, education, research, and audit, to achieve Primary Care Network and local population objectives.
To take an active role in risk assessment, supporting implementation of strategies to minimise risk. Ensuring incidents and near misses are reported, through promoting a no blame culture. Act in accordance with GP Practice and Statutory Guidelines and Policies, including Health and Safety initiatives. Will work in accordance with Network priorities and objectives.
Effectively manages own time, workload, and resources

Please refer the Job description for details