About this action

Patients with complex needs often fall through gaps between services despite MDT involvement. Dedicated care coordinators with responsibility for Focus Patients ensure plans translate into coordinated action and nothing is missed. Approaches to implementation: - Define care coordinator role including responsibilities - Recruit coordinators with skills in navigation and advocacy - Embed coordinators as equal MDT members and empower them to challenge when plans aren't implemented - Create systems for coordinators to track all actions - Build relationships across all services involved - Monitor impact on patient experience and outcomes Key benefits: Transforms MDT effectiveness by ensuring comprehensive plans become coordinated reality, particularly benefiting patients facing multiple disadvantages who struggle to navigate complex systems.