Care Co-ordination Service

Care co-ordination is defined as “a function to help ensure that a patient’s needs and preferences for health services and information sharing across people, functions and sites are met.” Co-ordinating care is especially important for people with chronic conditions and for the elderly, and it is for this group that the CCG is commissioning this service, as a first stage of its Whole Systems Integrated Care plans. The CCG anticipates that the Care Co-ordination staff will support care planning in GP Practices for these patients, acting for some as their Personal Assistant to ensure effective transfer of referral information, minimise poor communication between different services and ensure appropriate follow-ups of care. They will look to make every patient contact count for empowering patients by delivering a preventative/self-care agenda to improve their outcomes.