The Care Coordinator has the following key responsibilities in delivering health services:
Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care.
Support patients to utilise decision aids in preparation for a shared decision-making conversation.
Holistically bring together all of a person's identified care and support needs, exploring options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person.
Help people manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care, using tools to understand people's level of knowledge and confidence in skills in managing their own health.
Support people to take up training and employment, and to access appropriate benefits where eligible, for example, through referral to social prescribing link workers.
Assist people to access self-management education courses, peer support, or interventions that support them to take more control of their health and well-being.
Explore and assist people to access personal health budgets where appropriate.
Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals.
Support the coordination and delivery of MDTs within the PCN.
In addition to this, the Care Coordinator will deliver the following wider responsibilities:
Work with the GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, referring people back to other health professionals within the PCN where required and appropriate.
Raise awareness within the PCN of shared decision-making and decision support tools.
Support PCN staff and patients to be more prepared to have shared decision-making conversations.
Any other duties as may be requested by the Clinical Lead or Operations Director of the PCN.
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