Care Coordinator

The Care Coordinator plays a pivotal role within Windsor PCN,

supporting patients to navigate health and care services while ensuring they

receive coordinated, personalised care tailored to their individual needs.

Working closely with GP practices and the wider multidisciplinary team, the

post holder will proactively identify patients who may benefit from additional

support, particularly those living with long-term conditions, frailty, multiple

health conditions or complex social needs.

The role focuses on coordinating care across organisations, empowering patients

to take an active role in managing their health, reducing unnecessary hospital

admissions and ensuring patients can access the right care, at the right time,

from the right service.

The Care Coordinator will manage a defined caseload of patients, acting as a consistent point of contact for patients, unpaid carers and professionals involved in their care. The post holder will play a key role in ensuring patients receive coordinated, timely and person-centred support, helping them navigate health, social care and community services to improve their overall health, wellbeing and independence.

Working as part of Windsor Primary Care Network's (PCN) multidisciplinary ProActive Care Team, the Care Coordinator will collaborate closely with GPs, Practice Nurses, Social Prescribing Link Workers, Health and Wellbeing Coaches, other Care Coordinators and wider health and care professionals. They will support the development and implementation of personalised care and support plans, ensuring that patients' individual needs, preferences, circumstances and agreed outcomes are considered throughout their care journey.

The post holder will proactively identify patients who may benefit from additional support through clinical searches, population health management initiatives, practice referrals and multidisciplinary team meetings. This will include supporting people with long-term conditions, complex health and social care needs, frailty or other circumstances that may affect their ability to manage their health and maintain independence. They will help coordinate appropriate interventions, facilitate referrals and follow up actions to ensure patients are connected with the services best placed to meet their needs.

An important aspect of the role will be supporting preventative and anticipatory care, including assisting with care planning, coordinating support following hospital discharge and identifying opportunities to prevent avoidable deterioration in health. The Care Coordinator will encourage patients to take an active role in managing their health, accessing appropriate community resources and making informed decisions about their care.

The post holder will also support the identification and recognition of unpaid carers, ensuring their caring responsibilities are appropriately recorded and that they are offered information, advice and signposting to relevant support services. They will work to identify barriers to accessing care, including practical, social and digital barriers, and help patients and carers access services in a way that reflects their individual circumstances.

Accurate and timely record-keeping will be essential. The Care Coordinator will maintain confidential patient records using EMIS Web and other approved clinical systems, ensuring appropriate clinical coding, documentation of interventions and recording of agreed actions. They will work in accordance with organisational policies, confidentiality requirements, GDPR and Information Governance standards.

Through effective partnership working with primary care, community health services, adult social care, mental health services, hospital teams, voluntary and community organisations and local authority services, the post holder will help deliver seamless, integrated care across organisational boundaries.

The Care Coordinator will contribute to the ongoing development and improvement of PCN services by participating in audits, service evaluations, quality improvement initiatives and the implementation of new ways of working. They will support the PCN's commitment to improving patient outcomes, promoting independence, reducing health inequalities and delivering high-quality, proactive and personalised care to the local population.

Windsor Primary Care Network (PCN) brings together six GP practices serving approximately 73,000 registered patients across the Royal Borough of Windsor and Maidenhead. The practices work collaboratively to deliver high-quality, integrated healthcare that responds to the changing needs of our local communities.

At the heart of the PCN is our multidisciplinary ProActive Care Team, comprising Care Coordinators, Social Prescribers and Health and Wellbeing Coaches, working in partnership with GP practices and wider health and care professionals.

Our shared aim is to provide proactive, personalised and preventative support that improves patient outcomes, promotes independence and wellbeing, and helps reduce health inequalities. Through collaborative working and strong community partnerships, we support people to access the right care, at the right time, in a way that meets their individual needs.

Qualifications