Our Care Coordinators have a clinical background with care home experience. They work for the Primary Care Network communicating with the older people care homes on a weekly (sometimes daily) basis.

Our Care Coordinators organise the multi-disciplinary team (MDT) meetings to ensure that the right healthcare, social care and mental wellbeing professional are on board. This is what the care home staff say about the MDTs:

“The multi-disciplinary team meetings are the best thing to be implemented. The PCN Care Coordinators make sure the right people are on the call to help deal with residents’ complex healthcare issues. For example, one of our residents started to decline rapidly after recovering from Covid. Their overall health deteriorated with weight loss, repeated urine infections, and reduced mental wellbeing. During the MDT meeting, a plan was put in place to address the health concerns and a referral was made to the Parkinson’s Team. The resident is now off their medication, receiving the right treatment and their health is improving”.

“The multi-disciplinary meetings are well organised and planned. Time is given to each case to explore all healthcare and wellbeing avenues so that residents get the right treatment or referral to the right specialist team. The PCN Care Coordinators keep the care home informed of progress and we can pass that news on to reassure residents’ families”.

Our Care Coordinators organise multi-disciplinary team (MDT) meetings with our extended teams such as:

• older people mental health
• occupational therapists
• community nurses
• Parkinson team
• Listening and Responding to Care Home (LarCH) team

Our main aim is to help create a person centred care approach to our older patients who currently live in care homes. We do this by helping them, their families and friends to create individual care plans alongside the care home staff. This enables them to have a voice to allow choice in what care they receive in order to meet their needs, and retain as much independence as possible.

We also assist our Advanced Clinical Pharmacist in the delivery of structured medication reviews for care home residents. These reviews are completed on a yearly basis and they allow the resident to also have choice when possible, in their medication decisions.

Our Care Coordinators can also assist care homes with locating and sign-posting training for their staff. They can also help and support care homes who are struggling to meet the needs of their residents by organising training and support with the relevant teams.

Health and social care professionals, including care home staff, work together in a multidisciplinary team to provide care to residents. 

• Read how we deliver the Enhanced Health in Care Homes service