PCN Care Co-ordinator

• Coordinate and support the delivery of personalised care plans.
• Act as a central point of contact for patients and their families where appropriate.
• Support patients to access the right services at the right time.
• Coordinate care across primary care, secondary care, community services, social care and voluntary sector organisations.
• Facilitate smooth transitions between services.
• Ensure patients receive timely follow-up and ongoing support.
• Provide assessment within patient home settings.

• Identify patients who may benefit from care coordination including:
• Frail and elderly patients.
• Patients with multiple long-term conditions.
• Patients experiencing frequent hospital admissions.
• Patients with complex social needs.
• Patients requiring support from multiple agencies.
• Maintain patient caseloads and prioritise support according to need.
• Monitor progress against agreed care plans.
• Escalate concerns and risks appropriately.

• Work alongside patients to identify their needs, goals and preferences.
• Support shared decision-making.
• Promote self-management and patient activation.
• Support patients in understanding available healthcare and community resources.
• Assist in developing personalised care and support plans.

• Participate in multidisciplinary team (MDT) meetings.
• Coordinate actions arising from MDT discussions.
• Support communication between clinicians, practices, community teams and partner organisations.
• Facilitate information sharing in accordance with information governance requirements.

• Support proactive management of patients identified through frailty, population health and risk stratification programmes.
• Assist with long-term condition reviews and follow-up.
• Coordinate annual reviews where appropriate.
• Support implementation of PCN and Integrated Care System initiatives.

• Work closely with Social Prescribing Link Workers.
• Assist patients to access community-based services and support networks.
• Signpost patients to appropriate statutory and voluntary sector services.
• Support reduction of social isolation and health inequalities.

• Support patients following discharge from hospital.
• Assist with post-discharge follow-up activity.
• Coordinate actions arising from discharge summaries.
• Identify patients at risk of avoidable admission and work with the wider MDT to provide support.

• Maintain accurate patient records using clinical systems.
• Record activity in accordance with PCN, INT and contractual requirements.
• Produce reports and performance information as required.
• Ensure documentation is accurate, contemporaneous and compliant with information governance standards.

• Recognise and respond appropriately to safeguarding concerns.
• Follow local safeguarding procedures for children and adults.
• Escalate clinical and non-clinical risks promptly.
• Maintain patient confidentiality at all times.

• Contribute to continuous quality improvement initiatives.
• Participate in service evaluation and audit activities.
• Support implementation of new pathways and services.
• Share best practice and contribute to innovation across the PCN.

• Improve access to healthcare services.
• Deliver coordinated and personalised patient care.
• Support population health management.
• Reduce health inequalities.
• Strengthen links between primary care, community services, social care and the voluntary sector.
• Provide innovative services through the Additional Roles Reimbursement Scheme (ARRS).

Essential

• Experience working within health, social care, community or voluntary sector services.
• Experience supporting vulnerable individuals.
• Experience managing competing priorities and workloads.
• Experience communicating with a range of stakeholders and professionals.
• Experience maintaining accurate records and documentation.

Desirable

• Experience within General Practice or Primary Care.
• Experience of care coordination or case management.
• Experience working within multidisciplinary teams.
• Experience supporting frail patients or individuals with long-term conditions.
• Knowledge of NHS systems and services.

Desirable

• Care Coordinator Qualification or Personalised Care Institute training.
• NVQ Level 3 in Health and Social Care, Business Administration or equivalent experience.
• Health Coaching qualification.
• Level 3 or above qualification in health, social care or related field.
• Mental Health First Aid training.
• Safeguarding qualifications.

Essential

• Commitment to delivering high-quality patient-centred care.
• Flexible and adaptable approach to working across multiple sites.
• Ability to travel between PCN locations as required.
• Ability to perform home visits.
• Full UK Driving License and access to a vehicle.

Essential

• Understanding of person-centred care.
• Knowledge of confidentiality and data protection requirements.
• Understanding of safeguarding responsibilities.
• Awareness of health inequalities and wider determinants of health.
• Understanding of multidisciplinary working.

Desirable

• Knowledge of Primary Care Networks.
• Understanding of personalised care approaches.
• Knowledge of community and voluntary sector services.
• Understanding of frailty and long-term condition management.

Essential

• Excellent communication and interpersonal skills.
• Ability to build effective relationships with patients and professionals.
• Strong organisational and time management skills.
• Ability to work independently and as part of a team.
• Good problem-solving skills.
• Strong IT skills, including Microsoft Office applications.
• Ability to maintain confidentiality and professionalism.
• Ability to manage sensitive and potentially distressing situations.