Care Coordinators

We currently have a mixture of practice employed care coordinators and OneNorwich Practices (ONP) employed care coordinators, with roughly a 50/50 split.

Care coordinators support practice patient cohorts who require health checks/recalls for QOF, IIF, DES and CQC reports, the focus is to invite patients by using a month of birth recall system with a particular drive on mental health and learning disability engagement.

The role is quite varied practice to practice, depending on the practice/patient needs and current workforce. Here are some examples of some the work which is currently taking place at some of the sites:

  • Following-up with patients who recently discharged from hospital or have a change in medical circumstances, supporting the patients’ journey/needs, conducting welfare checks and/or arranging follow up appointments.
  • Conducting home visits with the GP to care homes, supporting patient, GP, PCP and gaining information from the care home staff.
  • Coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals. Raising awareness of how to identify patients who may benefit from shared decision-making. 
  • Supporting Norwich Primary Care Network (PCN) staff and patients to be more prepared to have shared decision-making conversations.
  • Utilising population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care. Helping people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care.
  • Coordinating multi-disciplinary working within the practice and facilitating onward referrals to external services.
  • Facilitate shared decision making with patients, their carers and clinicians.