Job Description

Care coordinators provide extra time, capacity and expertise to support patients in preparing for or in following-up clinical conversations they have with primary care professionals. They will work closely with the GPs and other primary care professionals within the practice to manage patients, making sure that appropriate support is made available to them and their carers; and ensuring that their changing needs are addressed.

Post holders will need to demonstrate flexibility and adaptability to working in a dynamic and busy environment.

Main duties of the job

The post holder will

Undertake work in line with practice/Primary Care Network (PCN) directed priorities.

Proactively identify and work with a cohort of people to support their personalised care requirements, using the available decision support aids.

Support the triaging of patients to ensure they are directed to appropriate care pathways.

Ensure regular and consistent communication with the referrer regarding patient progress and any complications or guidance.

Raise awareness of health promotion and NHS health checks in practices.

Support national screening programmes.

Monitor referrals to ensure tasks are completed and care delivered by keeping in regular telephone contact.

Direct liaison with agencies to coordinate care for patients.

To support patient/carer contact roles and collate patient and carer feedback on their experiences.

Support Quality and Outcome Frameworks and other DES specifications.

Maintain and develop engagement with all practice staff and encourage best practice.

Act as the first port of call for patients on their caseload in relation to their care.

Bring together patients identified care and support needs and explore their options to meet these into a single personalised care and support plan (PCSP), in line with PCSP best practice.

Help people to manage their needs, answering their queries and support them to make appointments.

Support people to take up training, employment, and access appropriate benefits where eligible.

Raise awareness of shared decision-making and decision support tools and assist people to be more prepared to have a shared decision-making conversation.

Ensure that people have good quality information to help them make choices about their care.

Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing, including using the Patient Activation Measure.

Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing.

Explore and assist people to access personal health budgets where appropriate.

Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers and other primary care roles.

Supporting residents in care homes/LD homes ensuring personalised care is delivered through collaborative working between health, social care, voluntary, community and social enterprise sector and care home partners.

Key working relationships

Patients, carers and family members

GP Practice staff

Community Teams

Wider community and secondary care services

Neighbourhood Teams

Social Prescribing Link Workers

Voluntary, Community and Social Enterprise (VCSE) Services

Social Care Services

Community pharmacists and support staff

Communication and record keeping

Develop strong working relationships with GPs and practice teams and other health care professionals.

Ensure that all relevant professionals are kept up to date so that any issues or concerns can be appropriately addressed and supported.

Proactively conduct follow-ups on communications from out of hospital and in-patient services.

Actively participate in multidisciplinary team meetings in the practice/PCN when appropriate.

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.

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

Provide feedback to relevant stakeholders about service progress.

General

Duty of Care: Put the interest and needs of the patients first and foremost.

Ensure that work is delivered in a timely and effective manner.

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

Contribute to the wider aims and objectives of the PCN to improve and support Primary Care e.g. cancer screening.

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

Undertake continual personal and professional development, providing evidence of learning where required.

Take an active part in regular appraisals.

Equal Opportunities

The Practice is committed to equal opportunities that affirm that all staff should be afforded equality of treatmentand opportunity in employment irrespective of sexuality, marital status, race, religion/belief, ethnic origin, age or disability. All staff members are required to observe equal opportunities in their behaviour to fellow employees.

Confidentiality

All employees are required to observe the strictest confidence with regard to any patient/client information that they may have access to, or accidentally gain knowledge of, in the course of their duties.

All employees are required to observe the strictest confidence regarding any information relating to the work of the Practice its employees. You are required not to disclose any confidential information either during or after your employment with the Practice, other than in accordance with the relevant professional codes. Failure to comply with these regulations whilst in the employment of the Primary Care Network could result in action being taken.

Data Protection

All employees must adhere to the appropriate and relevant national and local data and information governance procedures and principles on the protection and use of personal information. .

Health and safety

The Practice expects all staff to have a commitment to promoting and maintaining a safe and healthy environment and be responsible for their own and others welfare.

Risk Management

You will be responsible for adopting the risk management culture and ensuring that you identify and assess all risks to your systems, processes and environment and report such risks for inclusion within the Practice risk register. You will also attend mandatory and statutory training, report all incidents / accidents, including near misses, and report unsafe occurrences.

Safeguarding

Recognise and respond to safeguarding concerns in line with local policy. Seek supervision to guide safeguarding practice.

No smoking

The Practice supports 'no smoking'; therefore staff are not permitted to smoke whilst on duty. All staff members are expected to recognise their role as ambassadors for a healthy lifestyle. As such, staff should not smoke whilst in uniform, in NHS vehicles or on the Practice premises.

Other duties

There may be a requirement to undertake other duties as may reasonably be required to support the Practice.

Person Specification

Experience

- Achieved or willing to undertake a minimum 2 day course to support patient personalised care models e.g. from https://www.personalisedcareinstitute.org.uk

- Experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field (including unpaid work)

- Experience of data collection and providing monitoring information to assess the impact of services.

- Experience of partnership/collaborative working and of building relationships across a variety of organisations.

- Experience of working with or in general practice.

- Working in a multi-disciplinary setting where influence and negotiation is required.

- Knowledge/familiarity with medical terminology.

- Experience of supporting people, their families and carers in a related role (including unpaid work).

- Vulnerable adults' awareness.

- Experience of care of the elderly or frail

Skills and Knowledge

Knowledge of the personalised care approach

- Advanced experience of using word, excel and PowerPoint including ability to use word processing skills, emails and the internet to create simple plans and reports.

- Creative problem solver and willing to search for hard-to-find information.

- Meets DBS reference standards and has a clear criminal record in line with the law on spend convictions.

- Continued commitment to improve skills and ability in new areas of work.

- Knowledge of general practice clinical systems (EMIS).

- Ability to read large amounts of information and extract the salient points.

- Data analysis and reporting.

Qualifications

- Demonstrable commitment to professional and personal continuous development.

- GCSE Grade A to C (including English and Maths

Job Types: Full-time

Benefits:

On-site parking Pension Discounts
Work Location: In person

Job Type: Full-time

Pay: 12.50-13.50 per hour

Expected hours: 30 - 37 per week

Benefits:

Company pension Employee discount On-site parking
Work Location: In person

Application deadline: 15/08/2025
Reference ID: care co-ordinator mmc