LTC Proactive Care Coordinator

• MDT Coordination
• Call and Recall Processes
• EMIS administration and data quality
• Care planning support
• Performance and reportng

• Organise and coordinate regular LTC MDT meetings at practice, PCN or neighbourhood level.
• Prepare patient lists and case summaries for discussion.
• Record actions, outcomes and agreed care plans from MDT meetings.
• Track completion of MDT actions and follow up with relevant clinicians and services.
• Liaise with community, mental health, social care, voluntary sector and secondary care partners as required.
• Ensure MDT discussions support personalised and holistic care planning.

• Identify eligible patients for LTC reviews using approved searches and cohort criteria.
• Operate systematic call and recall processes for annual reviews, care planning appointments and follow-up interventions.
• Contact patients via telephone, SMS, letters and other approved communication channels.
• Monitor uptake and non-attendance and take appropriate follow-up action.
• Maintain accurate records of invitations, appointments and outcomes.

• Maintain and update patient records using EMIS.
• Apply agreed LTC templates and care planning tools.
• Ensure appropriate clinical coding and recording of care plan activity, wider determinants of health, personalised care discussions and MDT outcomes.
• Support data quality improvement by identifying coding gaps and outstanding actions.
• Run EMIS searches and reports to support performance monitoring and service delivery.
• Ensure information is recorded in accordance with PCN, ICB and information governance requirements

• Support delivery of the Year of Care approach.
• Assist patients to access appropriate services, including social prescribing, community services and self-management support.
• Ensure care plans reflect patient goals, preferences and identified needs.
• Support identification and recording of wider determinants of health.

• Monitor progress against LTC LIS targets and outcomes.
• Produce reports on call and recall activity, review completion rates and MDT outcomes.
• Escalate risks relating to performance, patient engagement or service delivery.
• Support practices and PCN teams to achieve contractual and quality requirements

Essential

• Grade C GCSE English and Maths or equivalent qualifications
• Minimum of 2 years experience working directly with people, families or carers in health, social care or a related support role, whether paid or voluntary
• Good communication skills (written and oral)
• Good interpersonal skills including observation, listening and empathy
• Intermediate IT skills, able to use Microsoft Office applications, e.g. Word, Excel and PowerPoint
• Ability to manage multiple priorities
• Demonstrates attention to detail, accuracy and numeracy skills
• Ability to work as a team member and autonomously
• Excellent organisational time management skills

Desirable

• MDT administration and minute taking
• Knowledge of LTC management programmes, QOF/LIS requirements
• Understanding of personalised care and care planning
• Population health management and data reporting
• Knowledge and ability to use GP IT system EMIS Web