What is Care Coordinators?
How Care Coordinators can help you...
- Prepares patients for conversations about their health and care
- Assesses and monitors health and care needs
- Takes a personalised approach, focusing on what matters to patients most, using personalised care support planning tools (PCSPs)
- Acts as the node of the GP surgery, being a single point of access for vulnerable patients with complex conditions
- Supports tackling health inequalities by proactively identifying areas of unmet need for practices and specific patients to work with or refer onwards
- Proactively identifies vulnerable or complex patients
- Can be practice or PCN based, which means they may work on wider priorities across several practices or at just one practice
Care coordinators also strengthen links between the PCN/practice and services involved in care e.g. care homes, ambulance services, prevention programmes. They save GPs and other professionals time by ensuring information about a patient is streamlined and easily accessible and helps practices and PCNs in multidisciplinary team working by connecting individuals and supporting MDT meetings.
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How Aylesbury Central PCN delivers Care Coordinators...
We have a dedicated Care Co-Ordinator and Pharmacist who form part of our multi-disciplinary team (MDT) visiting care homes on a weekly basis. We are also lucky to be able to offer our patients who live in a care home the access to Immedicare, 24/7 365 day a week acute service with access to nurses and geriatricians.
Care Homes MDT
A care home multidisciplinary team (MDT) is a group of healthcare professionals who work together to provide care for residents of a care home. The team typically includes a range of professionals with different expertise, such as doctors, nurses, physiotherapists, occupational therapists, and social workers.
The goal of an MDT is to provide coordinated and comprehensive care for residents, taking into account their physical, psychological, and social needs.
“The MDT is really helping with the medication provision for the residents. You are very responsive to requests and there is an improvement in the medication ordering and delivery. So thank you very much for what you are doing.”
Healthier Lifestyle, Happier You!
The X-PERT Weight & Wellbeing course is a 12-week group education programme to support anyone who would like to lose weight or improve their health in general.
An empowering and fun programme that explores the most effective methods to lose weight and keep it off. On the course you will address concerns that you have with your lifestyle, such as with your diet and physical activity levels.
We passionately believe in quality education and in long-term sustainable behaviour change and not short-term diet or lifestyle fads. We look at health holistically, offering choices with flexible options. This approach delivers multiple benefits well beyond weight loss including improving sleep quality, stress management, relationship with food and preventing future health conditions.
Features of the programme:
- Lifestyle & wellbeing education programme covering weight loss, managing stress, sleep quality, preventing future health conditions
- Flexible dietary approaches: Low carbohydrate, Mediterranean, Intermittent fasting, Real food and snacking avoidance
- 12 x Online Group Sessions
- Includes a printed Weight & Wellbeing Programme Handbook
NEW 12-week exercise programme
Exercise, mobilise and socialise
The feedback from participants regarding the course has been overwhelmingly positive, prompting us to plan for more 12-week programs in 2024!
The first cohort has successfully finished the 12-week Exercise Referral program, which consisted of weekly 1-hour sessions. Made up of 30-40 minutes of chair-based, body weight, and resistance-band exercises, followed by a 20–30-minute social period where participants could engage in discussions related to health and well-being. Each patient was provided with handouts containing still images and descriptions of exercises for home practice.
Upon completion of the 12-week program, our health and wellbeing coaches observed positive outcomes, including notable weight loss, reduced waist circumferences, improved flexibility, and mobility, and enhanced cardiovascular fitness.
Eat Well: 11 Healthy Recipes from our Health & Wellbeing Coaches
Get Active: Walking, Running, Cycling and Greenways
Get Running: Couch to 5k
Local Park Walks
St Peter’s Greenway
Haydon Hill Link
Waddesdon Greenway
Greenways and Cycleroutes: About Us
Other services
Please note, Aylesbury Central PCN’s online classes are only available to patient’s that have been invited via the Health & Wellbeing Coaching (HWC) service. If you would like to improve your health and wellbeing, please self-refer to the HWC service.
