Clinical Care Coordinator

Job summary

The Clinical Care Coordinator will be part of the Primary Care Network (PCN) Multi-Disciplinary Team (MDT) who are responsible for managing the care of people registered with practices within a Surrey Heath PCN. This role will involve face to face patient activity holding a patient case load and meeting patients at GP Practice, Care Home and in their own home amongst other designated clinical environments across Surrey Heath locality.

Within this role you will involve coordinating the work of healthcare professionals and non-clinical staff including volunteers involved in the care of patients registered at GP practices within the wider PCN population. The post holder will contribute to tackling inequalities in health and social care particularly regarding individuals with long-term conditions. Part of the role will be to undertake patient assessment and the planning the needs of patient cohort, as well as assisting in the administrative proactive work for SMRs and engaging in supporting all cancer reviews.

Main duties of the job

• Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care
• Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribers, health and wellbeing coaches and other primary care professional
• Support PCN staff and patients to be prepared to have shared Decision making conversations including utilising decision aids and tools, and support patients to understand their level of knowledge, skills and confidence.
• Help people to manage their needs through answering queries, making and managing appointments and ensuring that people have good quality written and verbal information to help them make choices about their care.
• Managing a cohort of patients who are in need of extra support and guidance their health needs, this could be face to face or via telephone consultations.
• Supporting the pharmacy and Wider PCN team with tasks and administration when required
• As part of the multidisciplinary team, build relationships with staff in GP practices within the PCN, attending relevant meetings, providing information and feedback on care coordination priorities
• Liaise directly with care home coordinator and team, compile and circulate relevant information across stakeholder Groups
• Supporting patients with cancer care reviews at different stages of diagnosis.
• Carrying out Phlebotomy Clinics within a clinical space

About us

We are Surrey Heath Community Providers Limited, which is a federation of 7 GP practices across 10 sites, covering a population of over 97,000 patients across Surrey Heath. We began in 2016 and now employ around 200 members of staff across our clinical and corporate support teams. Since 2019 we have hosted the Primary Care Network in Surrey Heath.

As a GP Federation, we are proud to represent our member practices and to champion primary care by working with local general practice and system partners in the provision of community based healthcare services. We are dedicated to providing safe and compassionate care to our patients across our range of primary care services in Surrey Heath and believe in continuous commitment to quality service delivery and positive patient outcomes.

Patients are at the heart of everything we do, and we pride ourselves in ensuring our patients feel safe, supported, communicated with and respected, at a time when they may be feeling vulnerable.