Care Coordinators
What are care coordinators?
Care coordinators work as part of the general practice multidisciplinary team (MDT) to identify people in need of proactive support; this could mean, as a examples, people living with frailty or with multiple long-term physical and mental health conditions. Care coordinators will work with these patients on a 1-2-1 basis, building trusting relationships, listening closely to what matters to them, and helping them to develop a personalised care plan.
As part of this work, care coordinators will review people’s needs and help to connect them with the services and support they require, whether that’s within the practice or elsewhere – for example, community and hospital-based services. They may support people in preparing for or following up clinical conversations they have with healthcare professionals, to enable them to be actively involved in managing their care and supported to make choices that are right for them.
They will work closely with social prescribing link workers and health and wellbeing coaches, referring people to them and also receiving referrals in return.
What are care coordinators?
the benefits provided by care coordinators, as follows:
- Care coordinators are the patient’s go-to person if their needs change or if something goes wrong with service delivery: the care coordinator ensures that there are no gaps in the patient’s service provision, as many elderly and disabled people with highly complex needs struggle to coordinate with all the relevant services directly on their own
- Care coordinators help improve patient education and understanding, and overall better health outcomes
- They can help patients in avoiding unnecessary appointments, procedures, and tests, and to feel more empowered and actively engaged in their treatment
- A 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
- By identifying high-risk patient populations before they incur costlier medical intervention, employers can begin to reduce both practice expenses and total NHS costs
- Employers can gain access to additional data that can reveal practice population health levels and risks; care coordinators glean information about patients’ treatment histories, medication adherence, new symptoms, and management of chronic conditions
What is their scope of practise?
According to Health Education England (HEE), a care coordinator should undertake the following activities, as part of their role:
- Proactively identifying and working with a cohort of people to support their personalised care requirements
- Supporting people to use decision aids in preparation for a shared decision making conversation
- Bringing together a person’s identified care and support needs and exploring their options to meet these into a single personalised care and support plan, in line with person-centred service plan (PCSP) best practice
- Helping people to manage their need, answering their queries, and supporting them to make appointments
- Supporting people to take up training and employment, and to access appropriate benefits where eligible
- Raising awareness of shared decision making and decision support tools and assisting people to be more prepared to have a shared decision making conversation
- Ensuring that people are well-informed, to help them make choices about their care
- Supporting people to understand their level of knowledge, skills, and confidence (Patient Activation Measure*) when engaging with their health and wellbeing, including through use of the patient activation measure
- Assisting people to access self-management education courses, peer support, or interventions that support them in their health and wellbeing
- Exploring and assist people to access personal health budgets where appropriate
- Providing coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches, and other primary care roles
- Supporting the coordination and delivery of multidisciplinary teams (MDTs) within PCNs
Is funding available for them?
Yes, care coordinators are included on the additional roles reimbursement scheme (ARRS), funding is available for them; from April 2020, this role can be reimbursed at 100% of actual salary plus defined on-costs, up to the maximum reimbursable amount of £29,135 over 12 months.
Any case studies?
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