Care Co-ordinator - HIPC PCN

Working as part of a multidisciplinary team (MDT), the post holder will support the proactive identification, care planning, and navigation of older adults and vulnerable patients living with frailty.

The core objective is to promote independence, safety, and wellbeing in the community, preventing avoidable deterioration and hospital admissions through robust signposting, home/community liaison, and physical observation monitoring under clinical guidance.

Main

Duties & Responsibilities

Frailty

& Community Hub Co-ordination

Frailty

Identification & Navigation

Support

the proactive identification and coding of moderately and severely frail

patients. Serve as a central point of co-ordination between GP practices, the

Community Frailty Hub, District Nurses, Community Therapy Teams, and Adult

Social Care.

Personalised

Care & Reablement Support

Assist in delivering person-centred care plans that encourage patient

independence, goal engagement, and safe living within their own homes.

Physical

Observations & Early Warning

Perform and accurately record basic physical observations (e.g., blood

pressure, pulse oximetry, blood sugar) when indicated or instructed by a

clinician. Monitor patients for subtle changes in condition and immediately

escalate concerns to clinical staff.

Assessment

& Visit Workflow

Facilitate first visit assessment documentation, maintain pre-visit summaries and

ensure pre-visit data is accurately communicated across the MDT.

Signposting

& Referral Pathways

Actively refer and signpost patients and carers to appropriate community

services, voluntary agencies, and reablement programmes (e.g., home exercise

plans set by therapy teams) to mitigate admission risks.

Cancer

Care & Prevention

Co-ordinate

contact with newly diagnosed cancer patients and monitor the 2 week wait

referral process.

Proactively

invite patients for screening (cervical, breast, bowel) and target

non-responders to increase uptake.

Track

necessary routine monitoring tests for cancer management and present

learning/data at monthly governance meetings.

End

of Life Care (EOLC) & Complex Needs

Assist

in identifying and correctly coding palliative and complex patients.

Ensure

regular annual and clinical reviews occur, assisting with correct DNAR record

coding and reviews.

Liaise

with social prescribing link workers, health/wellbeing coaches, and community

providers to manage physical and psychological needs.

Learning

Disabilities (LD) & Safeguarding

Support

LD register patients with annual reviews, accessible communications, and uptake

of preventative measures (flu/COVID jabs, screening).

Oversee

safeguarding workflow, record management, document summarising, and coding

across PCN practices, maintaining child/adult registers and liaising with MASH.

General

Administrative & MDT Duties

Maintain

accurate, timely electronic records (/EMIS Web) for all contact points,

ensuring CQC documentation requirements are met.

Participate

in vaccination call/recall campaigns and support practice reception/triage

cover when required.

Contribute

to safe service delivery through planned/unplanned cover and active involvement

in team training and 1-to-1 performance reviews.

Holistic Person-Centred Care Primary Care Network (PCN) consists of four GP surgeries in North Stoke-on-Trent, serving a diverse population of approximately 37,000 patients. Our mission is to work collaboratively to develop high-quality, sustainable services that improve health outcomes enabling our community to live well for longer while building a resilient future for primary care.

Experience

Skills & Competencies

Behaviours / Attributes

Qualifications