Primary Duties and Areas of Responsibility
Take overall responsibility for coordination and delivery of the weekly PCN led MDT meetings. A key role of the Care Coordinator will be to schedule the weekly 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. Utilise population health intelligence and PCN / Partner data 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 persons identified care and support needs, and explore 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 to 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.
Support people to take up training and employment, and to access appropriate benefits where eligible.
Support people to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure.
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