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Detailed job description and main responsibilities

As Care Coordinator your key responsibilities will include, but not be limited to:

Multidisciplinary Team (MDT) working

1. Arrange the EHAH led Huddles/MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified,
   and information circulated to team members in advance of the meeting. Record actions agreed at the meetings or take minutes and
   circulate as required
2. Consult with all members of the MDT to ensure its effective function.
   3. Work closely within the PCN roles, Community Services, Social Prescribing Link Workers, Community Matron, MDT and with GP practices within the PCN to ensure that
   the comprehensive records of MDT case discussions are entered into clinical systems, adhering to data protection legislation and data
   sharing agreements.
   4. Work as part of the MDT and wider PCN / Care Community to achieve its ICP (integrated care provider) directed objectives.

Referrals & Onward Referrals 

5. As part of the PCN MDT, build relationships with staff in each GP Practice within the PCN, attending practice meetings as required providing information and feedback on care coordination priorities.

6. Consult directly with Community services, Voluntary Sector, Acute Trust Ward Managers, Social Care, Practice staff and other key providers to identify
patients for discussion at MDT, and compile and circulate relevant information to attendees.

7. Refer patients to local services as required utilising providers referral processes.

Working with patients

8. Using clinical systems and data analysis to ensure a proactive approach to identifying patients that would benefit from review.

9. Alerting, referring or liaising with the relevant Service, Community Matron, professionals, family, and other services as required.

10. Raise awareness of shared decision-making and decision support tools and assist people to be more prepared to have a shared decision making conversation.

11. Work with patients, Carers, and professionals to deliver personalised care and support planning for patients.

12. Help people to manage their needs through answering queries, making, and managing appointments and ensure that patients have excellent quality information to help them make choices about their care.

13. Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing, including
through use of the tools.

14. Provide co-ordination and navigation for patients and their carers across health and care services, consulting with practice and PCN staff
including social prescribing link workers and health and wellbeing coaches.

15. Seek advice and support from the Community Matron/GP supervisor/Clinical Lead and/or identified individual(s) to discuss patient related concerns (e.g. abuse, domestic violence, and support with mental health), referring the patient back to the GP or other suitable
health professional if required.

16. To manage communications and social media pages to ensure patients have relevant and timely information to help them manage their health needs.

Personal/Professional development:

The post-holder will participate in any training programme implemented by the practice as part of this employment, with such training to
include:

 Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development.
Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work.
Complete mandatory training during probationary period.

Quality:

The post-holder will strive to maintain quality within the service and will:

Alert other team members to issues of quality and risk.
Assess own performance and take accountability for own actions, either directly or under supervision.
Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the team’s performance.
Work effectively with individuals in other agencies to meet patients’ needs.
Effectively manage own time, workload and resources.

Communication:
The post-holder should recognise the importance of effective communication within the team and will strive to:

Communicate effectively with other team members, GP practices, community services & other organisations.
Communicate effectively with patients and carers.
Recognise people’s needs for alternative methods of communication and respond accordingly.

Contribution to the implementation of services:

The post-holder will:
Apply all policies, standards and guidance.
Discuss with other members of the team how the policies, standards and guidelines will affect own work.
Participate in audit where appropriate.

This role is an expanding role that may require input into additional programmes and services