Job Description

for Patient Care Coordinator Job Title Patient Care Coordinator Line Manager Care Coordinator Supervisor Contract Type Permanent Working Hours 32 -38 hours per week Location Working across 4 surgeries Job Summary The Care Coordinator plays a key role within the Primary Care Network (PCN), proactively identifying and working with individuals particularly those who are frail, elderly, or living with long-term conditions to coordinate and navigate access to appropriate health and care services, ensuring they receive the right care, at the right time, from the right service. They work closely with GPs and practice 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. Care coordinators review patients needs and navigate patients to help them access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers and other professionals where appropriate. This non-clinical role focuses on improving the quality of life for patients by supporting them to manage their own health and ensuring they can access the right care and support when they need it.



Care Coordinators help patients navigate the healthcare system and connect with appropriate services to enable better health outcomes. They will be caring, dedicated, reliable and person-focussed and enjoy working with a wide range of people. They will have good written and verbal communication skills and 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 people, their families and carers with high quality support.



Training will be provided in care coordination, patient navigation, and relevant IT systems. Place of employment: The main places of employment are to be Rosebank Surgery, 153b Stroud Road, Gloucester, GL1 5JQ, Severnvale Surgery, St James, Quedgeley, Gloucester, GL2 4WD, Kingsway Health Centre, Rudloe Drive, Kingsway, GL2 2FY, Bartongate Surgery, 115 Barton Street, Gloucester, GL1 4HR and any other premises in Gloucester that the Practice may operate from. Key Responsibilities Work collaboratively with patients, their families, and carers to improve understanding of the individuals condition and support the development and regular review of personalised care and support plans to help manage their needs and achieve better health outcomes. Help individuals manage their health needs by responding to queries, arranging and managing appointments, and providing high quality written and verbal information to support informed decision making.



Support and guide individuals in accessing self-referrals, peer support, health coaching, and other interventions that promote health and wellbeing, empowering them to build the knowledge, skills, and confidence to manage their own care effectively. Assist individuals in accessing training, employment opportunities, and appropriate benefits, where eligible, such as through referral to social prescribing link workers. Identify unmet needs and refer patients to relevant services, including social prescribing link workers, community groups, mental health services, and voluntary sector organisations. Work in partnership with GPs and other primary care professionals within the PCN to proactively identify patients particularly those with long-term conditions who may benefit from care coordination or referral to additional support.



Maintain accurate, up-to-date records of patient interactions and interventions using relevant clinical systems (e.g. SystmOne). Support the development of effective communication pathways between general practice teams, patients, carers, and other agencies involved in care delivery. Identify and support unpaid carers, helping them access appropriate services and resources to meet their own needs.



Assist practices in keeping care records accurate and current by identifying and updating missing or outdated information about a patients circumstances. . Key Tasks 1. Enable access to personalised care and support a.



Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs; b. Develop a thorough understanding of the local health, social care, and voluntary sector landscape, and use this knowledge to navigate and signpost individuals to the most appropriate services and support at the right time. c. Work with the wider PCN, MDTs, and the social prescribing service to look at how carers can support people - this could include the initial identification of carers onto the carer register 2.



Coordinate and integrate care a. Making and navigating appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations b. Help people transition seamlessly between secondary and community care services and support people to navigate through wider the health and care system; c. Refer onwards to social prescribing link workers when required.



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



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; g. Work sensitively and respectfully with individuals, their families, and carers to gather relevant information that supports accurate care navigation and ensures their needs are appropriately met. h. Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service.



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 and practice teams and work collaboratively with other care coordinators and social prescribing link workers b. 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; c. Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning; d. Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities; e.



Work in accordance with the practices and PCNs policies and procedures; f. Contribute to the wider aims and objectives of the PCN to improve and support primary care.