PCN - Care Coordinator

at  Waltham Forest Federated GP Network

Job responsibilities 1. Facilitate and ensure the effective delivery of patient-centred, personalised health and social care plans for patients, monitoring progress and reporting outcomes, contributing to patient reviews and care planning within appropriate time frames 2. Explain the management of a patients pathway to clinical staff, liaising between services and service users, contacting services using the appropriate procedures/referral mechanisms 3. Work closely with all relevant care agencies (primary care, secondary care, community services, Mental Health, Social Services, Ambulance Service, Voluntary services and other relevant service providers) to ensure a coordinated and of the patients care plan, without requiring a further referral from the GP.
4. Maintain accurate records and statistical returns as required by the CCG, including providing patient-related information for entering into Clinical Reporting Systems, within the required time frame. 5. Ensure that a proper handover of care between different settings has taken place, including mutual transfer of all organisations communications & patient notes and ensuring care packages are set up 6.
Collect data on patients/carers for recognised outcome measure and document for service interpretation. Ensure all patient notes are updated to reflect any changes, including details on plans 7. Managing operational meeting processes, identifying patients for discussion and working closely with clinicians to define and lead the meetings. Organise and attend relevant meetings when required including Integrated Care meetings, ensure a programme of regular meetings is established, ensuring that all necessary documentation is circulated in advance 8.
Ensure that meeting actions are recorded, disseminated and followed up in a timely way; ensure relevant practitioners are aware of meeting decisions and actions / outcomes, and chase for action resolution and update. 9. Network and develop strong relationships with all levels of the NHSs key local players including the CCG, GPs and other primary care contractors, Social Services, Mental Health Trusts, Community Trusts, and other providers including the voluntary sector Be a contact point for GPs / practices and establish systems and processes which will ensure a timely and appropriate response to queries from clinicians and other stakeholder

Please refer the Job description for details