PCN MDT and Integrated Care Coordinator

• Alternate and support effective MDT meetings across S 1 PCN, ensuring they are well structured, outcome focused, and aligned with QOF requirements.
• Provide clinical coordination for patients with complex, long-term conditions, ensuring timely follow-up and continuity of care.
• Act as a central link between primary care, community services, social care, and voluntary organisations.
• Support identification and proactive management of patients with high levels of need.
• Ensure personalised care plans are developed, implemented, and reviewed.
• Promote integrated, person-centred care that addresses physical, mental, and social needs.
• Contribute to reducing health inequalities and improving access for undeserved populations.
• Monitor MDT activity and contribute to quality improvement and performance reporting
• Support delivery and assurance of LTC Proactive care QOF requirements.

We are looking for someone who

• Has experience in MDT coordination and/or clinical care coordination within the NHS, primary care, or community services.

• Has a strong understanding of long-term condition management and integrated care
• Is highly organised, proactive, and able to manage complex patient pathways.
• Has excellent communication and stakeholder engagement skills
• Can work effectively across organisational and professional boundaries.
• Is committed to improving patient outcomes and reducing health inequalities.

• Coordinate and optimise Multi-Disciplinary Team (MDT) working
• Provide clinical care coordination across pathways

• Coordinate and support regular, structured MDT meetings for South One PCN, ensuring alignment with LTC Proactive Care QOF requirements.
• Organise MDTs at practice, neighbourhood, PCN, RPN or Borough levels as locally determined.
• Ensure MDT meetings are focused on high-need patients and result in clear actions, ownership, and follow-up.
• Maintain consistent MDT processes, agendas, case selection, documentation, and tracking outcomes.

• Coordinate care for patients discussed within MDTs, ensuring timely follow-up of agreed actions and interventions.
• Act as a central point of coordination between primary care community services, social care, and voluntary sector partners.
• Support navigation of patients through complex care pathways, improving continuity and reducing fragmentation of care.
• Ensure personalised care plans or implemented, reviewed, and updated in collaboration with MDT members.
• Identify gaps in care and escalate concerns appropriately to clinical leads.
• Supports proactive management of patients at risk of deterioration, admission, or poor outcomes.

• Support identification and prioritisation of patients with multiple LTCs, frailty, or high risk.
• Ensure MDT discussions focus on high-risk and complex cohorts in line with QOF indicators.
• Facilitate development and review of proactive, personalised care plans

• Enable MDTs to deliver holistic, person-centred care planning covering physical, mental, and social needs.
• Promote shared decision making and continuity of care.
• Ensure MDT actions translate into coordinated and effective care delivery across South One PCN.

• Facilitate collaboration between primary care, community services, social care, and voluntary sector organisations.
• Ensure appropriate professional representation within MDTs .
• Promote Integrated ways of working to reduce duplication and improve patient experience.

• Ensure MDT And care coordination activity targets patients with health inequalities or barriers to access.
• Support production of on warranted variation across the South one PCN population.
• Align work with prevention, early intervention, and neighbourhood priorities.

• Monitor MDT activity and care coordination effectively against LTC proactive care quote indicators.
• Support collection of evidence demonstrating improvement in patient outcomes and service delivery.
• Use data, feedback column and learning to drive continuous improvement.

• Support delivery assurance for the LTC Proactive Care QOF within South One PCN.
• Provide reporting to PCN leadership, RPN, and ICB.
• Act as a key point of contact for MDT and care coordination-related performance matters.

• Be part of a forward-thinking PCN delivering innovative, proactive care models.
• Work within a supportive, collaborative neighbourhood team.
• Play a key role in shaping integrated care services locally.
• Opportunity to make a real difference to patients with complex needs.

Essential

• Educated to degree level or equivalent experience in relevant field (e.g. healthcare management, public health, nursing, allied health professional, or social care)
• Evidence of continuous professional development relevant to integrated care, care coordination, or service delivery
• Strong working knowledge of NHS systems, primary care, or community care environments

Desirable

• Professional modification in a health or social care discipline (e.g. nursing, AHP, social work)
• Training or certification and quality improvement methodologies (e.g QI, PD SA, Lean)
• knowledge or training related to long-term condition management, population health, or integrated care
• Understanding of LTC Proactive Care or similar NHS frameworks

Essential

• Experience working in a PCN setting.
• Knowledge of LTC Proactive Care QOF or similar frameworks.
• Experience in quality improvement methodologies.
• Understanding of population health approaches.

Desirable

• Effective and DTS delivering proactive, coordinated care.
• Strong clinical care coordination improvement patient pathways and experience.
• Improved outcomes for patients with long term conditions.
• Reduction in health inequalities across the PCN population.