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Care Coordinators

Care Coordinators are working with Primary Care Networks to support GP practices and their patients. Below describers three types of care coordinators:

  1. Dementia Care Coordinator 
  2. Frailty Care Coordinator 
  3. Learning Disabilities and Serious Mental Illness (SMI) Care Coordinator 

Dementia Care Coordinator 

A dementia care coordinator is a professional working within a GP practice that can support co-ordination of care needs for individuals diagnosed with dementia and cognitive impairment. This role is supported by Dementia forward.

What is dementia?

The term ‘dementia’ is used to describe symptoms where the Brain is affected by specific diseases and conditions. The following are the most common causes of Dementia:

  • Alzheimers
  • Vascular dementia
  • Fronto-temporal Lobe dementia
  • Dementia with Lewy bodies.

There are many more causes that affect people of all ages and backgrounds. Visit the NHS website for more information.

How can a Dementia Care Coordinator help me?

A Dementia Care Coordinator will support you from the point of diagnosis throughout your journey, ensuring you are treated to evidence based standards in accordance with agreed Care Plans. They will provide a clear and accessible point of contact for guidance, support and navigation, working closely with other health, social care organisations and voluntary agencies.

Some of the support you can expect from a Dementia Care Coordinator includes:

  •  ​Support pre and post diagnosis. 
  •  To make referrals into appropriate services to help support you and your family.
  •  To help support your independence. 
  •  To help you understand a new diagnosis and what to expect.
  •   A trusted point of contact within your GP practice - who can listen and guide you on what we can do to support. 
  • To ensure you feel supported, informed and able to obtain answers and information whenever you may need it.

How do I make an appointment to see a Dementia Care Coordinator?

Please contact your GP practice to ask if there is a dementia care coordinator supporting patients from your surgery. Not all GP practices in the Vale of York offer the same support roles.

Will I need to see the Dementia Care Coordinator on a regular basis?

Once referred to the dementia care coordinator the number of times you see them will depend on your needs. It is important you feel that you can access the Dementia Care Coordinator whenever you feel appropriate It may be that regular contact is needed for a period of time but then a more 'as and when' approach is right. 

Why is a Dementia Care Coordinator based in the GP surgery?

The Dementia Care Coordinator works closely with the whole team within the GP surgery. They work closely with the clinical staff to seek advice and guidance on different aspects of your care where necessary.

Resources

Leaflet - Practices in Selby Town Primary Care Network

Poster- Practices in Selby Town Primary Care Network

Frailty Care Coordinator

A frailty care coordinator holistically supports patients with mild to moderate frailty within the community. They work with patients to create a patient-centred care plan and provide access to support services within the area that are most appropriate for them. The role is a point of contact for both patients and their families and carers, whilst working alongside other health, social care and voluntary agencies.

What is frailty?

The term frailty or ‘being frail’ is often used to describe a particular state of health often experienced by older people.

If someone is living with frailty, it doesn’t mean they lack capacity or are incapable of living a full and independent life. When used properly, it actually describes someone's overall resilience and how this relates to their chance to recover quickly following health problems.

In practice being frail means a relatively ‘minor’ health problem, such as a urinary tract infection, can have a severe long term impact on someone’s health and wellbeing.

This is why it is so important that people living with frailty have access to well-planned, joined-up care to prevent problems arising in the first place – and a rapid, specialist response should anything go wrong.

 Age UK

How can a Frailty Care Coordinator help me?

The Frailty Care Coordinator will be a single point of contact for patients and their families/carers to call should any issues arise.

Some of the support you can expect from a Frailty Care Coordinator includes:

  • Formulation of care plans to ensure all care is patient centered reflecting your wishes, future treatment, next of kin etc.
  • Help with an array of social problems, from arranging flu vaccines, referring to other services such as Age UK for befriending services, or local fitness programs to ensure you maintain a good level of physical fitness which is suited to you
  • Signposting you and your family/carers to various social groups from which may be of benefit (once we are outside COVID restrictions).
  • Answering any queries you may have about your care.
  • A listening ear if something in your personal/care circumstances change and you're unsure of who to speak to. 

How do I make an appointment to see a Frailty Care Coordinator?

You can contact your GP surgery reception team and ask to speak to the Frailty Care Coordinator or alternatively you can phone directly. You can arrange to either see a Frailty Care Coordinator in person (at your home or the surgery) or a have a telephone appointment.

Will I need to see the Frailty Care Coordinator on a regular basis?

It is important you feel that you can access the Frailty Care Coordinator whenever you feel the need. You may feel that one appointment is sufficient however if you have more longstanding issues, the care coordinator will support you whilst the issues are resolved.

Why is a Frailty Care Coordinator based in the GP surgery?

The Frailty Care Coordinator works closely with the whole team within the GP surgery. They work closely with the clinical staff to seek advice and guidance on different aspects of your care where necessary.

Resources

Leaflet - Alice

Leaflet - Montana

Poster - Alice

Poster - Montana

Learning Disabilities and Serious Mental Illness (SMI) Care Coordinator

A learning disabilities and serious mental illness care coordinator holistically supports patients with learning disabilities and their carers within the community. They ensure patients care plans are agreed and personalised. The role provides an accessible point of contact for guidance, support and navigation whilst working closely with health, social care and voluntary agencies.

What is a learning disability (LD)?

A learning disability is a permanent condition which affects intellectual function and impacts on everyday activities. 

What is a serious mental illness (SMI)?

Mental illness is a range of emotional and psychological distress. This can be experienced by any person at any time but can be managed or overcome through treatment.

How can a LD and SMI Care Coordinator help me?

The role provides an accessible point of contact for guidance, support and navigation whilst working closely with health, social care and voluntary agencies.

 Some of the support you can expect includes:

  • Helps improve the health and wellbeing of people with learning disabilities
  • Helps improve the health and wellbeing of people with serious mental illness
  • A personalised care and support approach with you and your family/carers
  • Ensures your health and social care is planned and organized around your needs and preferences

How do I make an appointment to see a LD and SMI Care Coordinator?

You can contact your GP surgery reception team and ask to speak to the LD and SMI Care Coordinator or alternatively you can phone directly. 

Will I need to see the LD and SMI Care Coordinator on a regular basis?

The number of times you regularly access the LD and SMI Care Coordinator will depend on  your individual personalised care plan and needs. A discussion with you and your family/carers will ensure appropriate care is given and what type of ongoing support is needed.

Why is a LD and SMI Care Coordinator based in the GP surgery?

The LD and SMI Care Coordinator works closely with the whole team within the GP surgery. They work closely with the clinical staff to seek advice and guidance on different aspects of your care where necessary.

Resources

Leaflet

Poster

Feedback from local partner organisations and patients

The care coordinator & I have been in touch weekly as & when needed regarding various clients, to share information & build relationships with clients

I am finding that clients who know of her or have already been involved with her value her contribution, as she is able to look at a more holistic picture of things (as we try to) than the GP might; offering both support & signposting, building trust & passing on anything to the GP or other professionals that needs attention.

The Dementia Care Coordinator has made a great difference in the holistic support of people with dementia and memory problems at all stages in their journey. She is also helping raise the profile of dementia and the importance of diagnosis.

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