Care Coordinator

As part of the NHS’s commitment to improve health through personalised care, our Care Coordinator’s main goal is providing a more joined-up and coordinated care journey for patients and health care professionals. The team work with people who may need extra support to navigate the health and care system, helping to connect them to the right services or professionals at the right time.

Our Care Coordinators work closely with the GPs and other primary care colleagues within the primary care network. They act as a first point of access for care homes, the district nurses and vulnerable patients with complex conditions. They save GPs and other professionals time by ensuring that patient information is streamlined and easily accessible and helps the practices and the PCN in multidisciplinary team working by connecting individuals and supporting MDT meetings.

Care Home Support

• Our care coordinators work closely with local care homes, organising ward round visits on a weekly basis and working to agree and complete care planning for residents. They will also triage medication queries to the appropriate pharmacist or pharmacy technician.

Multi-Disciplinary Team (MDT) Meeting

• A care coordinator will chair a bi-weekly MDT meeting where group discussions can lead to quicker resolutions and more joined up care.

• These can be attended by healthcare professionals, social care workers, community based roles and local council departments.

• The goal of an MDT is to provide coordinated and comprehensive care for vulnerable patients and care home residents; taking into account their physical, psychological, and social needs.

Hospital Discharge Follow-Ups

• Our care coordinators will contact patients, aged 60 or over and live at home, who have an unplanned hospital visit where admissions last more than 24 hours.

• These are to minimise the risk of readmissions, identify any support needs, and help connect patients with local health, care, and community services to aid their recovery at home.

• Follow up with GP or referrals to District Nurses and other community services may also be required.