Nurse Care Coordinator

at  St Georges Medical Centre

Key Responsibilities Work with patients, their families and carers in order 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 patients to manage their needs through answering queries, making and managing appointments, and ensuring the patients have good quality written or verbal information to help them make choices about their care Support patients to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing Assist patients to access self-management education courses, peer support or interventions that support them in their health and wellbeing Support patients who take up training and employment, and to access appropriate benefits where eligible Provide coordination and navigation for patients 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 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 and to be more prepared to have shared decision making conversations Explore and assist patients to access a personal health budget where appropriate Key Tasks 1. Enable access to personalised care and support a. Take referrals for individuals or proactively identify patients who could benefit from support through care coordination b. Have a positive, empathetic and responsive conversation with the patient and their family and carer(s) about their needs c.
Support patients to develop and implement personalised care and support plans d. Review and update personalised care and support plans at regular intervals e. Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the patients care and uploaded to the relevant online care records, with activity recorded using the relevant codes f. Where a personal health budget is an option, to work with the patient and the local ICB to provide advice and support as appropriate 2.
Coordinate and integrate care a. Help patients transition seamlessly between services and support them to navigate through the health and care system b. Refer onwards to social prescribing link workers and health and wellbeing coaches where required c. 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 d.
Actively participate in multidisciplinary team meetings in the PCN as and when appropriate e. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975, and as such it will be necessary for a submission for disclosure to be made to the Disclosure & Barring Service (formerly CRB) to check for any previous criminal convictions. Communication The post holder should recognise the importance of effective communication within the team and will strive to: Communicate effectively with other team members Communicate effectively with patients and carers Recognise peoples needs for alternative methods of communication and respond accordingly Confidentiality In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers.
They may also have access to information relating to the practice as a business organisation. All such information from any source is to be regarded as strictly confidential Information relating to patients, carers, colleagues, other healthcare workers or the business of the practice may only be divulged to authorised persons in accordance with the practice policies and procedures relating to confidentiality and the protection of personal and sensitive data Qualities The post-holder will participate in any training programme implemented by the practice as part of this employment, such training to include: Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work Health & Safety The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the practice Health & Safety policy, the Health & Safety manual, and the Practice Infection Control policy and published procedures. This will include: Using personal security systems within the workplace according to practice guidelines Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks Making effective use of training to update knowledge and skills Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards Actively reporting of health and safety hazards and infection hazards immediately when recognised Keeping own work areas and general/patient areas generally clean, assisting in the maintenance of general standards of cleanliness consistent with the scope of the post-holders role Undertaking periodic infection control training (minimum annually) Reporting potential risks identified Demonstrate due regard for safeguarding and promoting the welfare of children Equality & Diversity The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include: Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with Practice procedures and policies and current legislation Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues Behaving in a manner which is welcoming to and of the individual, is non-judgemental and respects their circumstances, feelings, priorities and rights This job description is a reflection of the current position and may change in emphasis or detail in the light of subsequent development, in consultation with the post holder

Please refer the Job description for details