Patient Care Coordinator

at  The Fishponds Family Practice

Deliver reception services including call handling and appropriately triage and signpost patients to the most appropriate clinician and appointment. Expanding the care navigator role to incorporate new ways of working and support patients to Holistically bring together all of a persons identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person following the NHS Comprehensive Care Model. Contact hospitals to follow up referrals, liaise with hospitals for updates on patients or advice. Support patients to utilise decision aids in preparation for a shared decision-making conversation.
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, using tools to understand peoples level of knowledge, confidence in skills in managing their own health. Support and coordinate covid, flu and immunisation clinics. Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level. 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.
Work with the GPs and other primary care professionals to identify and manage a caseload of patients and, where required and as appropriate, refer people back to other health professionals. 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. Undertake all mandatory training and induction programmes. Contribute to and embrace the spectrum of governance.
Take part in the ongoing development of the role through participation in training and service redesign activities. Attend a formal appraisal with their manager at least every 12 months. Once a performance/training objective has been set, progress will be reviewed on a regular basis so that new objectives can be agreed. Contribute to public health campaigns (e.g., COVID-19 or flu clinics) through advice or direct care.
Maintain a clean, tidy, effective working area at all times. Support delivery of QOF and IIF, incentive schemes, QIPP and other quality or cost effectiveness initiatives. To carry out any other reasonable duties as requested by a manager to ensure a quality and efficient service

Please refer the Job description for details