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New roles in Leeds: Clinical Care Coordinators

With the increasing number of older people and those with long term conditions living in the community, it is more important than ever to earlier identify people at risk of deteriorating health in order to put supports in place so that they may stay as independent as possible and avoid admission to hospital.

A new role, Clinical Care Coordinator, is being developed in west Leeds GP practices, to help prevent these patients from being overlooked. Clinical Care Coordinators are part of the Primary Care Team in GP practices, and they review patients in the practice that are at greatest risk of failing health.

Lynne is a Clinical Care Coordinator and says of her role,

“I look at how patients are managing at home and if they are managing socially. I look at their health as a whole package and I ensure the right people are involved in their care to keep them as independent as possible.”

Lynne does this by initially contacting people over the age of 85 who are not part of the GP practice’s unplanned admissions work. She includes those at greatest risk to her case load so she may follow their progress and coordinate their care. Once she has assessed this group, she will then do a similar assessment for those aged 75-85 years old.

Lynne works closely with the Woodsley Neighbourhood Team (NT) assigned to the GP practice she works in. The NT is comprised of community health and social care staff that provide support for patients outside the GP practice. Lynne says that the joined up working is progressively getting stronger as the NT becomes more embedded in the GP practice. “We are getting to know our Neighbourhood Team. They now come to our monthly meetings where we discuss patients we are concerned about. We might not be sure where to refer the patient to, or we might need advice from a social worker – having input from the Neighbourhood Team invaluable.”

Conversely, if a patient no longer needs the services of the NT, the Community Matron in the NT can discharge a patient to the Clinical Care Coordinator with the assurance that they are still on someone’s radar. This way, even if a patient does not have a current need for services, their case is reviewed regularly to make sure things aren’t changing.

For Lynne, the best part of the role is the way everything is coming together and working as a team to support people, to enable them to stay as healthy and independent as possible. She says,

“It’s all about coordinating the care and bringing it all together to make sure the right person sees the patient at the right time for their needs.”

For more information on the role of Clinical Care Coordinators, please contact Karen Newboult, Locality Manager at Leeds West Clinical Commissioning Group, on karen.newboult@nhs.net.