Care Coordinator

This is an exciting opportunity to join our evolving Integrated Neighbourhood Team across 3 Harbours and Bosvena Primary Care Network. You will be working alongside our care coordinators, clinicians, community nursing teams as well as volunteer and community sector providers.

The role ofCareCo-ordinator is vital role within our Primary Care Network Integrated Neighbourhood Team (INT) proactively identifying cases, co-ordinating and navigating care and support across health, care and support services to provide apersonalised care approach. The Care Coordinator will act as a central point of contact to ensure appropriate support is made available to people and their carers; enabling them to understand and manage their conditions while ensuring their changing needs areaddressed.

Bosvena and 3H are seeking care co-ordination role primarily to support ouremerging frailty and health inequalities teams

The Care Coordinator will act as a central point of contact to ensure appropriate support is made available to people and their carers; enabling them to understand and manage their conditions while ensuring their changing needs are addressed.

Case Identification
:

• Support the team as required to undertake digital risk stratification
• Co-ordinate information for MDT platforms

Personalised Care and Support Planning (PCSP):

• Co-ordinate PCSP digitally
• Co-ordinate informational continuity including multi-agency meetings and communications
• Undertake clinical coding to create reliable patient records used for diagnosing accurately, planning treatment, and ensuring patient safety.
• Competently use clinical systems and templates to capture, and report patient records.
• Follow-up on communications from out of hospital and in-patient services.
• Work with commissioners, Integrated Neighbourhood Team members and other agencies to support and further develop the Care Coordinator role.

Coordinated and Multi-Professional Working:

• Be responsible for coordinating the care of each patient, ensuring close multi-agency and multi-professional working within the local Integrated Neighbourhood Team.

Our primary care network spans coastal, town and rural Cornwall including Bodmin, Fowey, Lostwithiel and Par. We are developing our Integrated Neighbourhood Team, working with social care, community partners, secondary care and voluntary sector providers, to deliver high quality, patient centred health care across our geography.

General

• Identify carers and help them access services to support them, ensuring they are coded as a carer on the GP clinical system if they are a patient at the Practice.
• Provide a single point of contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care.
• Assist people to access self-management education courses, peer support, health coaching and other interventions to enable them to better manage their health and wellbeing.
• Provide co-ordination and navigation across services, helping to ensure people and their carers receive a joined-up service and the appropriate support from the right person at the right time.
• Work collaboratively with GPs and other General Practice team members within the INT to proactively identify and manage a caseload, and where appropriate, refer back to other health practitioners within the PCN.
• Support the co-ordination and delivery of multidisciplinary teams with the PCN, if required.
• Identify people, using tools such as the Personalised Proactive Whiteboard, who may benefit from shared decision making and support PCN staff and people to be more prepared to have shared decision-making conversations.

Other responsibilities

• Applying PCN policies, standards and guidance.
• Contributing to the teaching and training of trainees, new employees and employees who are undertaking training, as appropriate.
• Awareness of and compliance with all relevant policies/guidelines for your role, e.g. prescribing, confidentiality, data protection, health and safety.
• Contributing to evaluation/audit and clinical standard setting within the organisation as applicable to…