Job Description

Job summary

Within the Enhanced Health in Care Homes (EHCH) Team, the Care Co-coordinator plays an important role within a Primary Care Network (PCN) to proactively identify and work with people living in care homes, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.

They work closely with General Practice and Neighbourhood teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers; supporting them and their carers to understand and manage their condition and ensuring their changing needs are addressed.

This is achieved by bringing together all the information about a persons identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.

The successful candidate will be caring, dedicated, reliable and person-focused and enjoy working with a wide range of people. They will have good written, verbal communication skills, IT skills, strong organisational and time management skills. They will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing patients with high quality support to meet the needs of our patient population.

Main duties of the job

Care Coordinators, review patients needs and help them and their carers access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers, health and wellbeing coaches, and other professionals where appropriate.

Care Coordinators alongside the EHCH team to build a long term working relationship with care homes.

This role essential to supporting the Care Home Multidisciplinary Team meetings whichrun weekly consisting of Care Home teams, General Practice, Neighbourhood Health and Social Care teams as all-encompassing approach to personalised care and promoting shared decision making whilst supporting clients with complex needs.

Please note that the role of a care coordinator is not a clinical role.

Overview of your organisation

Tone Valley PCN consists of 5 like-minded Somerset practices; Lyngford Park Surgery, Taunton Vale Healthcare, Creech Medical Centre, Warwick House Medical Centre, North Curry Health Centre and are responsible for the care of around 36,500 patients.

Salary: based on indicative Agenda for Change Band 4

Interview: expected to take place week commencing 24 November 2025 at Creech Medical Centre

Key responsibilities

The aim of EHCH is to provide proactive and personalised healthcare for people with multiple long-term conditions, including frailty and health inequalities delivered through multi-disciplinary teams in local communities. Working with clinicians to provide support in care homes with an emphasis on self-management and prevention of avoidable illness, whilst, building a long-term working relationship with care homes.

Provide coordination and navigation for health, social care and neighbourhood services helping to ensure patients receive a joined-up service and the most appropriate support.

Provide coordination of weekly care home rounds across the PCN.

Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify residents who would benefit from Muli-Disciplinary Team review and where appropriate, refer to other health professionals within the PCN / Neighbourhood.

Support the coordination, administrative tasks and delivery of multidisciplinary teams with the PCN.

Support professional meetings, inclusive of minuting the Multidisciplinary Team meeting and Multi Agency Risk Meetings as required by the team.

Carry out holistic assessments to aid patients in managing any long-term conditions they may have, supporting self-management and access to care.

Work closely with patient families and or advocates to enable them to support their loved ones in decision making and personalised care planning.

Support PCNs in developing communication channels between GPs and Care Homes including in reaching into secondary care services and follow up post discharge.

Liaise with key stakeholders as needed for the collective benefit of the patient.

Maintain accurate and timely records of referrals and interventions to enable monitoring and evaluation of the service.

Support practices to keep care records up to date by identifying and updating missing or out-of-date information about the patient's circumstances.

Contribute to risk and impact assessments, monitoring and evaluations of the service.

Cross cover care-coordinators and administrative duties within the Proactive Care Team as required by the service.

Key Tasks

1. Enable access to personalised care and support:

a.Take referrals for individuals or proactively identify patients who could benefit from support through care coordination;

b. Support patients to develop and implement personalised care and support plans;

c. Review and update personalised care and support plans at regular intervals;

d. Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the patient's care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes;

2. Coordinate and integrate care:

a. Help to transition seamlessly between services and support them to navigate through the health and care system;

b. Refer onwards to appropriate health and social care professionals where required;

c. Facilitating a coordinated approach to care and ensuring effective communication between teams for accurate records;

d. Actively participate in multidisciplinary team meetings in the PCN and individual practices as and when appropriate. This may include minuting and administrative tasks that arise from the meeting;

e. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported;

f. Identify when additional support is needed alerting a named clinical contact in addition to relevant professionals and highlighting any safety concerns;

g. Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation;

h. Encourage patients to provide feedback and to share their stories about the impact of care coordination on their lives;

i. Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service;

j. Run necessary reports as required by the EHCH team;

k. Complete necessary administration responsibilities as required by the EHCH Team;

3. Professional development

:

a. Work with a named clinical point of contact for advice and support;

b. Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required;

c. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety;

4. Miscellaneous

:

a. Establish strong working relationships with GPs, practice teams, care homes and work collaboratively with other care coordinators, social prescribing link workers and health and wellbeing coaches, supporting each other, respecting each others views and meeting regularly as a team;

b. Act as a champion for personalised care and shared decision making within the PCN;

c. Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner;

d. Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning;

e. Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities;

f. Work in accordance with the practices and PCNs policies and procedures;

g. Duties may vary from time to time without changing the general character of the post or the level of responsibility;

h. Contribute to the wider aims and objectives of the PCN to improve and support primary care;

i. To support in the delivery of the PCN Network DES, enhanced services and other service requirements on behalf of the PCN;

Agreement

This is flexible, and the post holder will be expected to undertake any other duties appropriate to the role as may be required by the PCN. This is subject to change from time to time with organisational need and the post holders agreement should not unreasonably be denied.

Qualifications

Essential:

- Grade 4 GCSE standard pass in English Language and Mathematics.

- Demonstrable commitment to professional and personal development.

- Ability to use Microsoft Office applications - Word, Excel, PowerPoint, Outlook.

- Access to own transport.

- Ability to travel across the locality.

Desirable:

NVQ Level 3 in adult care - advanced level or equivalent qualifications or working towards

Experience

Essential:

- Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity).

- Experience of working within multi- professional team environments.

- Experience of supporting people, their families and carers in a related role.

- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation.

- Experience of administrative duties / minute taking.

- Experience of data collection and using tools to measure the impact of services.

- Basic knowledge of long-term conditions and the complexities involved: medical, physical, emotional and social.

Desirable

- Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement.

- Experience or training in personalised care and support planning.

- Knowledge/familiarity with medical terminology.

Pay: Dependent on experience - based on Band 4 AfC

This job is based in Taunton and travel across the five GP practices and sites is a requirement for this role

Interviews are expected to take place week commencing 24 November 2025 at Creech Medical Centre

Application deadline: 20 November 2025

Job Type: Full-time

Pay: 14.06-15.43 per hour

Education:

GCSE or equivalent (required)
Experience:

working in health, social care and other support roles: 1 year (required)
Licence/Certification:

Driving Licence (required)
Work Location: In person

Application deadline: 20/11/2025
Reference ID: A3705-25-0002