Care Coordinator

Job summary

People are increasingly affected by living with complex, long term health conditions, growing unmet health needs and the effects of other social determinants of health. The NHS is expanding the Primary Care workforce to help tackle these issues, with the aim to reduce the health inequalities people experience.

Care coordinators identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.

The Post holder will work along side the Lead Nurse as a point of contact for care homes and housebound patients . Providing practical , emotional and social support to patients ,carers and partners is a fundamental requirement of this role.

Supporting those with chronic conditions ,frail/elderly and often vulnerable people the care coordinator offers effective intervention in supporting people to stay well .The skill to assess people's changing needs is required as is a desire to bring together multi disciplinary teams to support peoples complex health care needs .

Routinely the post holder will manage patient lists to maintain the health needs of those with chronic long term conditions such as asthma, diabetes and Coronary Heart disease. This will require excellent time management , effective communication and organisational skills to monitor and invite patients for health reviews annually.

Main duties of the job

Primary Responsibilities

Administrative management of patients with long term conditions incl. Asthma, COPD, CHD, Diabetes and prediabetes, stroke and TIA

Management of annual review invitations and reminders

Sending Florey questionnaires to obtain clinically relevant information to ensure patient information is up to date and appropriate

Organise Blood tests as necessary for health reviews

Experience of SNOMED coding

Management of QOF registers for chronic disease

Processing of retinopathy screening letters

Maintaining the lists of housebound and care home patients ensuring this information is accurate and kept up to date

Manage reviews for housebound and care home patients

Prepare patient summaries for annual reviews

Responsible for the on call Care home mobile and direct line

Preparation of Weekly care home ward round list

Process all admin/documents for care homes incl. online service

Working with other teams across Champ PCN to offer optimum care to this elderly /frail patients

Signposting to other services as appropriate

Updating patient records

Organising MDT meetings

Actioning and distributing tasks from the meetings to the relevant service providers and co-workers .

Working closely with the clinical team to maintain high levels of patient care:

About us

Witterings medical centre is a forward thinking Practice . Teamwork is at the centre of everything we do to ensure we provide quality care to our patients . We encourage multidisciplinary working and believe that this variety of disciplines offers a productive ,mulit-functional team resulting in improved outcomes ; this also adds to patient and employee satisfaction .