Care Coordination

What is Care Coordination at Three Shires Medical Practice?

Care Coordination

A Care Coordinator works in a doctor’s surgery to help patients understand their health and get the care they need. They make sure all the different people helping the patient — like doctors, nurses, and other services — work well together. They also help patients learn how to manage their health and connect them with support groups or organisations that can help.

At the surgery we have three Care Coordinators:

Sarah: is the team lead and works closely with both patients and staff to make sure care runs smoothly. She helps invite patients for their annual reviews, especially those with long‑term conditions such as asthma, high blood pressure, and diabetes. Sarah also supports clinics such as respiratory testing. In addition, she helps monitor cancer care, arranges wheelchair measurements and referrals, and supports the day‑to‑day processes of the care coordination team.

Victoria supports our housebound patients, patients living with dementia, and older patients who may be lonely or socially isolated. She helps ensure these patients receive appropriate support and regular contact where needed. Alongside this, Victoria oversees our cervical screening processes and arranges wheelchair measurements and referrals to support patients’ mobility needs.

Sadie: supports people who care for family members or friends (carers). She can refer carers to the monthly Carers Surgery and ensures they are included on the Practice’s Carers Register. She also supports patients with learning disabilities or severe mental illness, making sure they are invited for their annual reviews and have access to any support they may need. In addition, Sadie manages cancer care pathways and NHS Health Checks.

If you would like to speak to a care coordinator, please let the reception team at your surgery know and they can put you in contact.

Long -Term Condition Yearly Review Information

Why You Should Go to Your Yearly Review

If you have a long-term health condition, like asthma, diabetes, or high blood pressure, it's important to see your health care assistant or nurse every year.

These check-ups help keep you safe and well.

What Happens at Your Review?

We take a blood sample
We check your blood pressure
We look for any early signs of problems
We may arrange follow ups as needed with nurses, pharmacists or GP's.

Why It Matters

Even if you feel fine, your condition can change over time.
A yearly review helps stop small problems from becoming big ones.

When Will I have My Review?

We aim to review all long-term health conditions around your birth month.

We will let you know when you can to book your appointment. This will be through a text or letter.