Health Care

Coordinators

Our health care coordinator team connect people to vital, non-clinical support services in their local community.

It’s estimated that 1 in 5 GP appointments are about social rather than health issues. Our Health Care Coordinator Team is a proactive service, aimed at improving patients’ wellbeing alongside their health.

The Team

The Health Care Coordinator Team fulfill a previously unmet need.

GPs had seen an increase in people coming to them with non-clinical issues because they had no one else to go to. The Health Care Coordinator Team was originally designed to support older or frail patients. Since the remit has changed, the team now support a range of ages including Learning Difficulties, End of Life, the Chronically ill and the vulnerable. The Health Care Coordinator team has also widened their clinical skills to help the cross over between social and medical problems. 

Our team has a range of backgrounds, both inside and outside of the NHS, but they share a single priority: the needs of the patient come first.

How it works

GPs can refer people in need of help to our specialist team.

From there, our team carry out thorough assessments to understand the patient’s needs and talk with them about what extra help they might need.

Together the Health Care Coordinator Team make a personalised care plan for each patient they see. From this, support can be given covering a range of issues such as care packages or home equipment.

Patients’ needs can also be matched to appropriate social or community groups.

A case study on the origin of the HCC team can be found here.

How it helps

We liaise with hospitals to ensure a safe discharge for patients.

We attend discharge meetings at Darlington Memorial Hospital, University Hospital of North Durham and Bishop Auckland Hospital.

Creating a positive relationship with hospital staff through good communication benefits our patients.

The longer a patient stays in hospital, the more susceptible they become to infections. We want to get our patients back to their homes as safely and quickly as possible. Appropriate and safe discharges reduce the risk of readmission for patients.

Outcomes:

214%
Increase in Service Use*
30
Patients Visited Every Week
125%
Increase in Early Discharges**

* 17/18 compared to 18/19

** January-December ’19 compared to previous 12 months

 

Katy has been with DDHF for over a year.

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Katy Smith, HEALTH CARE COORDINATORI visit patients at home and look at different aspects of their lives to ensure they are safe, happy, looked after and able to manage day-to-day tasks. 

I enjoy working with older people, getting to know them and hopefully having a positive impact on their lives. They’re often forgotten members of society – I enjoy giving them a voice and making them feel valued.

The best part of my job is gaining a patient’s trust, building a relationship and helping improve their health, wellbeing and happiness.