PCN Care Coordinator

• Building trusting, person-centred relationships with patients and carers.
• Coordinating care across GP practices, community services and social care.
• Supporting patients before and after appointments, helping them prepare and understand the next steps.
• Creating clear, personalised care plans that reflect individual goals and priorities.
• Attending and supporting MDT meetings and making sure agreed actions are followed through.
• Acting as a consistent point of contact for patients, families and professionals.
• Working closely with the wider PCN Living Well Team to help people remain well and independent.
• Using information and data responsibly to support service improvement and patient experience.

• Enjoy working directly with patients and carers.
• Are a good listener who communicates clearly and kindly.
• Can manage a varied workload while staying organised and calm.
• Feel confident working independently but value being part of a team.
• Are comfortable using IT systems and learning new ones.
• Care deeply about dignity, inclusion and high-quality patient care.

• Provide coordination and navigation for people and their carers across health and care services, alongside working closely with our Living Well Team (Social Prescribing Link Workers, Frailty Nurses and Care Coordinators) and all members of our primary care teams.
• With the support of the Practice and Network proactively identify a cohort of people in need of anticipatory coordinated support, using local knowledge and population health intelligence.
• Lead the organisation, coordination and delivery of MDTs within the PCN - including producing the Agenda and taking minutes.
• attend the MDTs, recording and following up actions within defined timescales agreed during the meeting.
• Improve continuity of care by acting as a point of contact for people, families and professionals.
• Bring together a person's identified care and support needs and explore their options to meet these into a single personalised care and support plan.
• Ensure that people have good quality information to help them make choices about their care and structure conversations using a coaching approach.
• Provide time, capacity and expertise to support people in preparing for or following up on clinical conversations with health professionals.
• Work with members of the primary care teams to develop and implement data collection systems that will provide accurate and timely data to monitor and evaluate services.
• Raise awareness within the PCN to shared decision making and decision support tools.
• Raise of awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to shared decision making conversations.

Essential

• Compassionate, empathetic and person-centred approach to supporting patients and carers.
• Commitment to dignity, inclusion, equality and high-quality patient care.
• Calm, professional and resilient when working with people with complex needs.
• Willingness to undertake further training and development, including progression to an Advanced Care Coordinator role.
• Ability to undertake home visits as part of the role.
• Access to own transport and ability to travel between PCN sites.
• Eligible to work in the UK (no visa sponsorship available).

Essential

• Compassionate, empathetic and person-centred approach to supporting patients and carers.
• Commitment to dignity, inclusion, equality and high-quality patient care.
• Calm, professional and resilient when working with people with complex needs.
• Willingness to undertake further training and development, including progression to an Advanced Care Coordinator role.
• Ability to undertake home visits as part of the role.
• Access to own transport and ability to travel between PCN sites.
• Eligible to work in the UK (no visa sponsorship available).

Essential

• Good standard of education with 5 GCSE's or equivalent.
• Good IT skills, especially a working knowledge of MS Office (Word, Excel, Powerpoint and Outlook).
• Commitment to continuing professional development, including the Personalised Care Institute Course(s).

Essential

• Experience of working in a patient-facing, client-facing or support role (e.g. healthcare, social care, voluntary or community setting.
• Understanding of patient-centred care and supporting individuals with complex needs, including long-term conditions or frailty.
• Experience of working with multiple services or professionals to support individuals effectively.

Desirable

• Experience of working within the NHS, primary care, social care or a similar health or community setting.
• Experience supporting older people, frail patients or individuals with long-term conditions.
• Experience of multidisciplinary team (MDT) working and contributing to care planning or reviews.

Essential

• Excellent communication skills with the ability to listen, build rapport and communicate clearly and compassionately with patients, carers and professionals.
• Ability to build trusting, supportive relationships with patients and carers.
• Strong organisation skills, with the ability to manage a varied workload and prioritise effectively.
• Ability to work independently, using initiative, while also working effectively as part of a multidisciplinary team.
• Confident in using IT systems, including Microsoft Office, patient records and digital tools, with willingness to learn new systems.

Desirable

• Experience of care coordination, care planning or navigating health, social care and community services.
• Experience of coordinating care, following up actions and acting as a point of contact for patients and professionals.
• Experience using clinical systems, preferably EMIS, and/or SystmOne.