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Care Co-ordinator
The closing date is 29 August 2025
Carecoordinators play an important role within the surgery to proactively identifyand work with people, including the frail/elderly and those with long-termconditions, to provide coordination and navigation of care and support acrosshealth and care services. They work closelywith GPs and practice teams to manage a caseload of patients, acting as acentral point of contact to ensure appropriate support is made available tothem and their carers; supporting them to understand and manage their conditionand ensuring their changing needs are addressed. This is achieved by bringingtogether all the information about a persons identified care and support needsand exploring options to meet these within a single personalised care andsupport plan, based on what matters to the person.
Main duties of the job
Enhance inclusivity by improving access to difficultto contact patients, such as the homeless and those who cannot get transport.
Act as safeguarding administrator working closelywith the Doctors, health visitors and school nurse to organising quarterlysafeguarding meetings, take minutes and support actions that need to takeplace.
Support reception with Care Navigation and beavailable to the Same Day Team for support.
Support patient care between internal departmentsand external services to navigate them through the care system.
Provide coordination and navigation for people,especially vulnerable patients or those with complex needs, and their carersacross health and care services, working closely with socialprescribing link workers, health and wellbeing coaches, and other primary careprofessionals; helping to ensure patients receive a joined-up service and themost appropriate support.
Engage with other healthcare providers and fill outreferral forms for patient support services, such as for wheelchairs,Occupational Therapy or Care Farms for example.
Identify unpaid carers and help them access servicesto support them
Work with people, their families and carers toimprove their understanding of the patients condition and support them todevelop and review personalised care and support plans to manage their needs andachieve better healthcare outcomes.
About us
Cutlers Hill Surgery is a rural practice with approximately 10500 patients. We are a part of the South Waveney Alliance Network (SWAN).We have a well-establishedpractice team including 4 GPS, 4 UCPs, one of which specialises in homevisiting, 4 Nurse Practitioners, 4 Practice Nurses, 2 HCAs, 2 physios, 2 MentalHealth practitioners, 2 clinical pharmacists, and a SocialPrescriber, along with a fantastic administrative team. The practice iscommitted to innovation, development and providing excellent patient care. Weare looking for a dedicated professional who shares the same values to join us.
Job responsibilities
Summary
Carecoordinators play an important role within the surgery to proactively identifyand work with people, including the frail/elderly and those with long-termconditions, to provide coordination and navigation of care and support acrosshealth and care services. They work closelywith GPs and practice teams to manage a caseload of patients, acting as acentral point of contact to ensure appropriate support is made available tothem and their carers; supporting them to understand and manage their conditionand ensuring their changing needs are addressed. This is achieved by bringingtogether all the information about a persons identified care and support needsand exploring options to meet these within a single personalised care andsupport plan, based on what matters to the person.
Responsibilities
Enhance inclusivity by improving access to difficultto contact patients, such as the homeless and those who cannot get transport.
Following up low tier mental health disorders andsupporting the mental health clinicians.
Identify when action or additional support isneeded, alerting a named clinical contact in addition to relevantprofessionals, and highlighting any safety concerns.
Act as safeguarding administrator working closelywith the Doctors, health visitors and school nurse to organising quarterlysafeguarding meetings, take minutes and support actions that need to takeplace.
Support reception with Care Navigation and beavailable to the Same Day Team for support.
Support patient care between internal departmentsand external services to navigate them through the care system.
Help people to manage their needs through answeringqueries, making and managing appointments and ensuring that people have goodquality written or verbal information to help them make choices about theircare.
Work collaboratively with GPs and other primary careprofessionals within the surgery to proactively identify and manage a caseload,which may include patients with long-term health conditions, and whereappropriate, refer back to other health professionals within the surgery.
Provide coordination and navigation for people,especially vulnerable patients or those with complex needs, and their carersacross health and care services, working closely with socialprescribing link workers, health and wellbeing coaches, and other primary careprofessionals; helping to ensure patients receive a joined-up service and themost appropriate support.
Engage with other healthcare providers and fill outreferral forms for patient support services, such as for wheelchairs,Occupational Therapy or Care Farms for example.
Identify unpaid carers and help them access servicesto support them
Support practices to keep care records up to date byidentifying and updating missing or out-of-date information about thepersons circumstances
Work with people, their families and carers toimprove their understanding of the patients condition and support them todevelop and review personalised care and support plans to manage their needs andachieve better healthcare outcomes.
Actively participate in multidisciplinary teammeetings within the surgery where appropriate.
Any other duties that the practice feels arenecessary
LCS/QOF/Recalls
Be involved in LCS/ QOF/ Recalls/ searches as required(e.g. proactive healthcare and inclusion LCS)
Inclusion Health non-clinical Champion
OtherDuties specific to Cutlers Hill Surgery Care Co Team
Memory screening & Referral to memory clinic
ADHD Screening & referral
ASD Screening & referral
Wellbeing check ins vulnerable patients
Applying for Attendance allowance
School refusals / liaising with school to supportchild
Attending MDT Meetings when required
Care needs/ support needs discussions Onwardsreferral to social care If needed.
Applying for blue badge
Applying for Attendance allowance, carers allowanceor PIP
Supporting patients completing forms
Signposting to weight management services
Signposting to disabilities advice service
Signposting for financial support services/ benefits
Signposting/referral for Isolation and befriending
Sign posting to domestic abuse services
Support with housing issues
Signposting to food bank/ community larder
Person Specification
Experience
* Minimum of 2 years experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field (desirable)
* Experience in use of databases
* Experience of administrative duties
* Able to demonstrate a clear understanding of working with
* confidential information and an understanding of service user
* confidentiality
* Working in a multi-disciplinary setting where influence and
* negotiation is required
* Knowledge/familiarity with medical terminology
* Working in a busy and demanding environment whilst
* delivering in a timely manner
* Understanding of current issues facing the NHS (desirable)
* Understanding of health and social care processes (desirable)
Qualifications
* ECDL or equivalent
* Ongoing internal and external training to keep up to date with changes/ developments
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Employer name
South Waveney Alliance Primary Care Network
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