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Care Coordinator Job Plan

Overview

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Objectives:

Working to ensure highest level of support for patients with complex health and social care needs.
Managing our patients with proactive coordination of their care.
Assisting all clinicians in the management of patients with long term conditions (LTC).

This page is designed to provide an overview of your typical daily duties. Please note that there may be some site variations based on room availability, staffing levels, clinical meetings, and / or PLTs.

Daily Schedule

Time	Task / Activity
9 am - 10 am	Tasks, emails and any non-patient facing actions
10 am - 12:30 pm	Face-to-face patients, telephone appointments or home visits
12:30 pm - 2 pm	Tasks, referrals, any urgent matters, preparing agendas, attending and chairing meetings
2 pm - 3:30 pm	Preparing meeting minutes and telephone appointments
3:30 pm - 5 pm	Tasks, registers, referrals, any actions that need to be done from earlier meetings

Regular Duties

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Care Coordinators must always review the Patient Clinical Alert/QOF box to ensure any patient unmet needs are addressed (e.g. alerts for Personal Care & Support Plan review, repeat blood test(s), blood pressure check, or any review/procedure that may be due). See 🗨️Pink Alert (QOF) Box.

1️⃣ Yearly Reviews

Providing yearly reviews for at risk populations:

Moderate/severe frailty → Personal Care & Support plans
Dementia → see 😖Dementia
Learning Disability → see ☀️Learning Disabilities

This includes contacting patients on frailty and house bound (HB) registers to invite them for annual review, and discussing in clinical meeting (CM) if appropriate.

Medical concerns identified in a review appointment are to be raised with the appropriate clinician and followed-up, to ensure action is taken.

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For urgent concerns → utilise pink slots and Duty Doctor lists. POST can be used to determine route of care if you’re unsure.

2️⃣ Emails

Access 📧Generic Surgery Inbox to review and action emails to and from:

patients, their families and carers
outside agencies working directly with patients (e.g. social services, occupational therapy, etc.)

3️⃣ Registers

The two Teams registers are to be checked and maintained regularly.

The register entitled “Safeguarding” contains adult & child safeguarding MARAC.
The one entitled “Registers” contains patients:

with learning disability
with dementia
with frailty
under palliative care
that are house bound (HB)

4️⃣ EMIS

All patient activity is to be recorded on EMIS at the time of the consultation, accurately and meticulously, to support and promote proactive care and safety for patients.

If a patient is discussed in a clinical or multi-disciplinary team (MDT) meeting, record this in patient notes, including a brief outline of actions to be performed with regard to the patient’s care.

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All meeting discussion notes on EMIS regarding patients should be hidden from online visibility.

5️⃣ Tasks

Tasks to be actioned in order of importance. Although not an emergency service, our team must react appropriately to, and prioritise certain types of situations.

Examples of tasks:

requests from GPs for welfare calls
safeguarding concerns
newly diagnosed cancers
new/existing palliative patient information
patient queries/concerns from receptionists/call handlers

6️⃣ Meetings

Coordinate Clinical Meetings (CMs) and Multi-disciplinary Team (MDTs) meetings.

Duties include:

inviting the relevant people → within Penrose Health and from outside agencies, where appropriate
preparing the agenda
supplying attendees with the agenda via Microsoft Teams
recording meeting and taking minutes
adding minutes to surgery “meeting logs”
updating EMIS patient notes if patient discussed in meeting

Ensure that all actions concluded in the meetings are followed up.

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Possible referrals:

Adult social care
Adult safeguarding
MASH
Strength and balance clinics
Foot clinics

Memory clinics
Wheelchair support
Social prescribers
Age UK
Benefit support

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If you have any questions about the duties or schedule above, please speak to your Line Manager. There may be some site variations based on room availability, staffing levels, clinical meetings and PLTs.