We have an exciting and innovative new opportunity for a Care Co-ordinator working on the Proactive Care project for Bridgwater Bay Primary Care Network. The role involves working with a team of clinicians to enable people to live healthy independent lives and support active self-management and prevention. The candidate will possess excellent communication and organisation skills and have experience in a Health, Social Care or Educational background workplace. Candidates should have excellent IT skills and have an interest in collecting data from clinical systems to help develop the service and support the PCN Management Team. The successful candidate will join our growing PCN workforce and support the delivery of care bringing together all the information about a patient's identified care and support needs and exploring options to meet these by identifying and signposting to appropriate clinicians. Patient needs will be discussed at MDT meetings with clear plans put into place to support people in our community. Care coordinators play an important role within a PCN to proactively identify and work with people to provide coordination and navigation of care and support across health and care services. They work closely with GPs and practice teams to support patients in the community, acting as a central point of contact to ensure appropriate support is made available to them; supporting them to understand and manage their condition and ensuring their changing needs are addressed.,
* Working with clinicians to provide support in neighbourhood areas with an emphasis on self-management and prevention of avoidable illness.
* Provide coordination and navigation for health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support.
* Support the coordination and delivery of multidisciplinary teams with the PCN.
* Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision making conversations.
* Support PCNs in developing communication channels between GPs and other agencies.
* Maintain records of referrals and interventions to enable monitoring and evaluation of the service.
* Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the patient's circumstances.
* Enable access to personalised care and support.
* Take referrals for individuals or proactively identify patients who could benefit from support through care coordination.
* Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the patient's care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes.
Bridgwater Primary Care Network (PCN) is the largest PCN in Somerset with 9 GP practices, a health & wellbeing hub and a diverse population spread across town and rural locations.
As a PCN we are forward thinking, innovate and driven to deliver the best patient care for our population. This includes health population management, and this role ties in with supporting that and tracking the improvements we can make to patients lives. In January 2023 we started an exciting joint venture with Somerset NHS Foundation Trust to open a Health and Wellbeing Hub at the old Victoria Park Medical Centre. This is a flagship hub, the first of its kind that will bring together Primary and Secondary care all under one roof to support the Bridgwater Bay community. The focus of the hub is preventative care and supporting self-care management to the population.
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