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Care Coordinator Role

    • Arrange and hold CST meetings every 6 weeks, to review and manage complex patients

    • Make onward referrals for patients to relevant services such as social services, intermediate care, community mental health team, voluntary services as required

    • Provide courtesy calls to all elderly patients when discharged home from hospital

    • Provide courtesy calls to any patients identified as vulnerable

    • Review all A&E/OOH visits, follow up as needed/required

    • Work closely with community matron to manage complex patients

    • Arrange support groups for patients:

    • Carers group held at surgery on 24/07/18 with Creative Carers organisation to provide support to those in a carer’s role. This group was well received by patients and so will take place on a regular basis in surgery. There will be different themes, as well as arranging professionals from different organisations to attend to help support these carers.

    • Fibromyalgia support group set up at the local mosque. Physiotherapist/Nutritionist attends to provide support and advice. Last support group was held on 16/07/18. This was well received by the local community and so will be held on a monthly basis, with the next one scheduled in September.

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