We are a non-clinical, non-patient facing role that attempts to bring closer collaborative working across teams and organisations. We are based within Primary Care Networks (PCNs) across the City. This means we have a geographical focus that enables us to respond and adapt to local health needs.
As Care Co-ordinators we are responsible for the co-ordinating information to support assessment of patient. GPs and members of the PCN neighbourhood team such as Community Matrons, Community Nursing, Cardiac Rehab, the Integrated Care Homes team and Community Rehab and Falls can access the Care Co-ordinators. PCNs also have an integrated Social Worker to provide help and advice.
We are an integral part of the delivery of Multi-Disciplinary Team (MDT) meetings. We use risk stratification software to identify patients with gaps in clinical care that may require a health or social care intervention in order to reduce hospital presentations. Any complex cases identified are brought to a regular MDT discussion hosted at the patient’s GP practice and chaired by a practice GP with standing invites to members of the neighbourhood team. It is our responsibility to set up MDT meetings, invite participants, write the agenda, take minutes and report back on actions from previous meetings.
Other responsibilities include:
- Tracking community patients in and out of hospital in order to support a safe discharge.
- Daily checks of patient records identified by risk stratification software in order to identify possible care gaps.
- We have access to patient records across the health system, including GP practices, community services, social care and hospital. We check these systems on behalf of clinical staff in order for them have to have the most up to date and relevant information in order to better make decisions.
- Inform community teams of hospital admissions in order to avoid wasted community visits.
- Contact hospital wards for updates on a patient’s condition in order to inform community teams.
- Inform community teams of hospital discharges to make sure patients are referred back to community teams after a hospital stay.
We also processing referrals on behalf of the following teams, in order to free up clinical time:
- The Neighbourhood Team (Community Nurses and Community Matrons)
- Community Rehab and Falls
- Social Care (excluding safe guarding referrals)
- Medicines Management
- Assistive Technology
Referrals come directly to us from health professionals. Patients cannot refer directly into this service.