PAC Relational Care Coordinator

1. Patient Care & Support

2. Care Coordination & Monitoring

3. Escalation & De-escalation

4. MDT Working

5. Holistic & Preventative Care

6. Safeguarding & Risk

7. Information Management & Quality

1. Patient Care & Support

Act as a named point of contact for patients with complex care needs.

Develop and maintain effective, therapeutic relationships with patients and carers.

Provide person centred support to enable patients to actively engage with their care plans.

Support patients to navigate health, social care, and voluntary sector services.

2. Care Coordination & Monitoring

Monitor patients with established care plans through regular contact (telephone, digital, or face to face).

Identify changes in patient condition, wellbeing, or circumstances.

Ensure care plans are regularly reviewed and updated in collaboration with MDT members.

Maintain accurate, contemporaneous clinical records in line with organisational policies.

3. Escalation & De-escalation

Recognise early signs of deterioration, increased risk, or unmet needs and escalate appropriately.

Support timely intervention through MDT coordination to prevent avoidable deterioration or hospital admissions.

Identify opportunities for de-escalation where patient needs have stabilised, ensuring safe transition to lower levels of support.

Participate in risk stratification and case management processes.

4. MDT Working

Participate in regular MDT meetings, contributing updates on patient status and care planning.

Coordinate actions from MDT discussions and ensure follow-up.

Liaise effectively with GPs, nurses, social prescribers, pharmacists, community services, and secondary care.

Promote integrated, joined-up working across services.

5. Holistic & Preventative Care

Support a holistic approach addressing physical, mental, and social needs.

Signpost and refer patients to appropriate services, including social prescribing and community resources.

Encourage self-management and preventative health behaviours.

6. Safeguarding & Risk

Identify safeguarding concerns and take appropriate action in line with local policies.

Maintain awareness of risks associated with complex patient groups (e.g., frailty, long term conditions, mental health).

Escalate concerns promptly to appropriate professionals.

7. Information Management & Quality

Maintain accurate data entry and documentation within clinical systems.

Support service audits, reporting, and evaluation activities.

Contribute to continuous improvement initiatives within the PCN and MDT model.

Responsibility for Patient/Client Care

Responsible for coordinating care for a defined caseload of patients with complex needs.

Required to exercise judgement within defined parameters and escalate where necessary.

Ensures care remains aligned with agreed care plans and patient goals.

Policy & Service Development

Contribute to the development of MDT processes and care coordination pathways.

Implement local and national policies relevant to the role.

Responsibility for Information Resources

Accurate recording of patient interactions and care updates.

Compliance with GDPR, confidentiality, and information governance requirements.

Responsibility for Research & Development

Participate in audits and service evaluations.

Support evidence-based practice within MDT working.

Freedom to Act

Works within clearly defined protocols and procedures.

Exercises initiative within scope of role, escalating complex decisions to senior clinicians or MDT.

Sutton Primary Care Networks is the collaborative vehicle for the four Sutton PCNs and the former Sutton GP Federation working together as a single entity. We are a Community Interest Company that aims to reinvest surpluses back into general practice and primary care for the benefit of our practices and the people who form the communities we serve.

Sutton has four PCNs whose boundaries are based on historical relationships and groupings of organisations. There are some similarities of residents health and care needs unique to a particular PCN, and many more needs that are shared across all four PCNs.

Our four PCN represent all 22 GP surgeries in Sutton. Their collective footprints cover all of the London Borough of Sutton and its residents who are able to access and benefit from the services and improvements offered by Primary Care Networks.

Primary Care Networks (PCNs) are a key part of the NHS Long Term Plan, with all general practices being required to be in a network by June 2019, and CCGs/Integrated Care Boards (ICBs) being required to commit recurrent funding to develop and maintain them.

The networks will have expanded neighbourhood teams which will comprise a range of staff such as GPs, pharmacists, district nurses, community geriatricians, dementia workers and Allied Health Professionals such as physiotherapists and podiatrists/chiropodists, joined by social care and the voluntary sector.

Qualifications

Experience