Care Coordinator - General Practice

Key Tasks 1. Enable access to personalised care and support a. Take referrals for individuals or proactively identify people who could benefit from support through care coordination working closely with our frailty and mental health teams. b. Have a positive, empathetic, and responsive conversation with the person and their family and carer(s) about their needs. c. Support people 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 persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes. 2. Coordinate and integrate care a. Help people 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 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. d. Actively participate in multidisciplinary team meetings in the practice 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. f. Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation. g. Work sensitively with people, their families, and carers to capture key information, while tracking of the impact of care coordination on their health and wellbeing. h. Encourage people, their families, and carers to provide feedback and to share their stories about the impact of care coordination on their lives. i. Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service. 3. Professional development a. Work with a named clinical point of contact for advice and support. b. Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required. c. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety. 4. Miscellaneous a. Establish strong working relationships with GPs and practice teams and work collaboratively with other Care Coordinators, social prescribing link workers and health and wellbeing coaches, supporting each other, respecting each others views, and meeting regularly as a team. b. Act as a champion for personalised care and shared decision making within the practice. c. Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner. d. Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning. e. Contribute to the development of policies and plans relating to equality, diversity, and reduction of health inequalities. f. Work in accordance with the practices policies and procedures. g. Contribute to the wider aims and objectives of the practice to improve and support primary care.