Health and Wellbeing Team Clinical Care Coordinator

This Care Coordinator position is a critical post in the continued success of the award winning TWNS PCNs Health and Wellbeing Team. The team are embedded at the heart of our five practices, building longstanding relationships with our local diverse community and provide lifelong care across this broad geographical community. The team are committed to understanding and responding proactively to the needs of our most vulnerable patients, supporting them to enjoy good health and independence and for as long as possible. This clinical role is an integral part of the PCNs multidisciplinary team, working under the Lead Nurse and alongside our Health and Wellbeing Coaches, to provide an all-encompassing approach to personalised care; promoting and embedding the proactive personalised care approach across the PCN. The role provides a central coordination function for patient care planning: undertaking both face-to-face and telephone appointments with patients, performing routine clinical tasks
such as phlebotomy, BP monitoring, and supporting some of our associated patient groups, as required. In addition, the role oversees safeguarding administration, document handling, record management and communication with partner organisations across health and social care. Main Responsibilities 1. Facilitate and ensure the effective delivery of proactive, patient-centred, personalised care for identified cohorts of patients across the breadth of the work of the Health and Wellbeing Team, inclusive of frailty, dementia and cancer. This will involve monitoring progress and reporting outcomes, contributing to patient reviews and care planning within appropriate timeframes. 2. Explain the management of a patients pathway, liaising between services and service users, contacting services using the appropriate procedures/referral mechanisms. 3. Work closely with all relevant care agencies (primary care, secondary care, community services, voluntary services and other relevant service providers)
to ensure coordinated delivery of the patients care plan, without requiring a further referral from the GP. 4. Maintain accurate records and statistical returns as determined by the Lead Nurse, including providing patient-related information for entering into SystmOne, within the required timeframe. 5. Adhere to infection prevention control policies 6. Collect data on patients/carers for recognised outcome measure and document for service interpretation. Ensure all patient notes are updated to reflect any changes, including details on plans. 7. Organise and attend relevant meetings when required including supervision, PCN meetings, multi-disciplinary team meetings etc, ensuring that any necessary documentation is circulated in advance. 8. Contribute to audits and data collection to aid evaluations of the PCN services will be needed. 9. Advise patients on diet, lifestyle as well as physical and mental wellbeing, along with signposting to local services and funding they may be eligible to
access. 10. Be a contact point for the TWNS PCNs practices and establish systems and processes which will ensure a timely and appropriate response to queries from clinicians and other stakeholders.