Care Cooordinator

About Personalised Care

Personalised care represents a new relationship between people, professionals and the health and care system. It provides a positive shift in power and decision making that enables people to have a voice, to be heard and be connected to each other and their communities.

This approach learns from the experience of social care in embedding personalised care in everyday practice, which has enabled people to take control over the funding for their care. It also builds on pockets of progress made in health.

Critically, personalised care takes a whole-system approach, integrating services around the person including health, social care, public health and wider services. It provides an all-age approach from maternity and childhood right through to end of life, encompassing both mental and physical health and recognises the role and voice of carers. It recognises the contribution of communities and the voluntary and community sector to support people and build resilience.

Care Co-Ordinator Overview

Care co-ordinators play an important role within a PCN to assess population health needs and identify cohorts of patients that will most benefit from personalised care, including the frail/elderly and those with multiple long-term physical and mental health conditions- to provide navigation and coordination of care and support across health and care services.

The care co-ordinator role will ensure patient health and care planning is timely, efficient, and patient-centred. This is achieved by bringing together all the information about a person’s identified care and support needs and exploring options to meet these.

Responsibilities

• Proactively identify and work with a cohorts of people, appropriate to the population needs of the PCN e.g. cancer care, Learning Disability and Autism, Dementia, Care Homes etc.
• Work with people individually, building trusting relationships, listening closely and working with them to develop a personalised care and support plan, based on what matters to the person.
• Help patients in avoiding unnecessary appointments, procedures, and tests, and to feel more empowered and actively engaged in their treatment
• Create more seamless service provision significantly decreases the risk of the patient deteriorating and thereby reduces the overall cost of care, and the likelihood that additional interventions will be needed in future
• Identifying and support high-risk patient populations before they incur costlier medical intervention
• Review people’s identified needs and help to connect them to the services and support they require, whether within the practice or elsewhere.
• Support to create a richer picture on practice population health needs and risks; by gaining information about patients’ treatment histories, medication adherence, new symptoms, and management of chronic conditions
• Support the coordination and delivery of multidisciplinary teams within PCNs.

Training

Supervision

The employing PCN must identify a first point of contact for advice and support and (if different) a GP to provide supervision for the Care Co-Ordinator. This could be provided by one or more named individuals within the PCN.

A PCN will ensure the Care Co-Ordinator can discuss patient related concerns and be supported to follow appropriate safeguarding procedures (i.e. abuse, domestic violence and support with mental health) with a relevant GP.