Neighbourhood Care Coordinator

The Neighbourhood Care Coordinator will act as the central point of contact for INT-eligible patients, coordinating their care within the Neighbourhood Integrated working model. The role will support proactive, personalised care for residents with complex needs, frailty, multiple long-term conditions, children and young people, and those who face barriers to accessing or engaging with services. The post holder will proactively identify and engage patients, undertake structured holistic reviews, capture patient goals and wider wellbeing needs, develop personalised care plans, coordinate access to clinical reviews and multidisciplinary team (MDT) meetings, and ensure agreed actions are followed through. In addition, they will support care coordination workflows, prioritisation and escalation processes, contribute to quality improvement activity, and provide supervision and support to care coordination colleagues.

Neighbourhood Care

Coordination

Act as a senior point of contact for patients, carers,

practices and partner organisations.

Proactively contact patients to understand their

needs, priorities, goals and barriers to care.

Complete structured

holistic reviews, capturing clinical, social and wider wellbeing factors and providing good quality written or verbal information

to assist with choices about care.

Prepare for clinics by ensuring patient records are up to

date and include any tests required by the clinic.

Follow up on post clinic tasks effectively (such as

making referrals, multiple disciplinary team (MDT) meeting preparation etc).

Develop, record and coordinate personalised care plans in line with

patient goals and local protocols.

Arrange any follow-ups, updating patient notes accordingly and

pro-actively check these tasks have been completed.

Signpost or refer patients to appropriate health,

social care, voluntary sector and community services.

Maintain accurate records, including Universal Care

Plans and shared care records where appropriate.

Prioritise caseload activity and escalate risks,

safeguarding concerns or clinical issues appropriately.

Provide guidance and day-to-day support to care coordination colleagues to share learning and best practice.

Ad-hoc neighbourhood tasks as

and when services require this.

Support the CYP

Programme by coordinating recalls for children and young people with tracer

conditions, ensuring timely follow-up and accurate record keeping.

MDT and Partnership

Working

Work with the neighbourhood primary care team to identify

cohorts of patients who are eligible for neighbourhood services. In Southwark

we currently have 3 priority areas: frailty, multiple long term conditions and

children & young people but as neighbourhood services expand, additional

priority areas will be identified.

Prepare, coordinate and refer appropriate cases for MDT discussion.

Track MDT actions and escalate delays or unresolved issues.

Work with the MDT to ensure consistent, patient-centered support across

the INT pathway.

Collaborate with primary care, mental health, nursing teams, community

services, social care, and voluntary

sector partners.

Support safe information sharing and improvements to neighbourhood

pathways.

Help to embed the MDT approach across the neighbourhood.

Collaborate with administrative teams to support the

organisation, coordination and smooth running of MDT meetings.

Build strong relationships with local partners and help

shape the services to improve outcomes for all.

Service Improvement

Support daily workflow, caseload prioritisation and task allocation.

Build and

maintain effective relationships with neighbourhood practices, Primary Care

Network (PCN), existing practice-based primary care co-ordinators and

neighbourhood teams.

Provide coaching and support to colleagues.

Contribute to SOPs, templates and pathway improvements.

Support audit,

reporting and quality improvement activity by collating patient data to help inform future service decisions.

Identify key themes, escalate

and report service risks, challenges and improvement opportunities to the INT

Manager

Resident Engagement and

Support

Build trusting relationships to understand patient

needs, priorities and barriers.

Use motivational interviewing and goal-setting

techniques to support engagement in the INT programme.

Encourage and empower patients to take an active role

in their health and care planning.

Support patients with low health and digital literacy,

communication needs or complex social circumstances.

Promote self-management, prevention and access to

community support.

Support patients to access and manage their

Universal Care Plans through the NHS App including signposting to digital

inclusion and support services.

Quay Health Solutions CIC and Improving Health Limited, our two established GP federations in Southwark, are working in partnership with Guys and St Thomas' NHS Trust (GSTT) to provide the Integrator function for Southwark.

Integrators are organisations within each borough that will seek to provide the core infrastructure to support effective integrated neighbourhood team working as it develops, ensuring services are tailored to meet local community needs and operate smoothly across organisational boundaries. Their role is critical in creating cohesive, proactive, targeted, and sustainable services that place individuals and communities at the centre.

Southwark is a diverse borough made up of five neighbourhoods: Bermondsey & Rotherhithe, Borough, Peckham & Nunhead, Camberwell & Walworth, and Dulwich. Each neighbourhood has distinct population needs, requiring tailored approaches to health and care delivery.

Experience

Qualifications

Knowledge and Skills

Values and Behaviours