Job Description

Ashfield Medical Centre - Colton Mill Medical Centre - Family Doctors - Manston Surgery

Job Summary

Our Care Coordinators play an important role within the PCN to reduce health inequalities and support meeting our PCN and practice targets. They work closely with practice and PCN staff to identify, engage with and coordinate personalised care and support planning for the most vulnerable people in our community, including the frail/elderly, patients with dementia and their carers, patients diagnosed with cancer, care home residents and those with long-term health conditions.

As well as being linked with individual practices they will work together as a team. This includes sharing learning and best practice both within the team and across the PCN.

Our Care Coordinators support Clinical Leads and the Multi-Disciplinary team in the organisation and facilitation of MDT meetings including weekly Care homes meetings.

They run reports to proactively identify eligible patients and work to increase uptake of health checks, cancer screening, vaccinations and other services including self-management services. Support with patient engagement, which includes ensuring that information is accessible for all and having conversations with patients and carers to increase understanding, alleviate concerns and increase engagement and self-management.

They support people in preparing for or following-up clinical conversations with primary care professionals (including health checks) to enable them to be actively involved in managing their care and supported to make choices that are right for them. You will use knowledge of health and social services available in the locality, including those offered by the community and voluntary sector, to link people up with these and help them overcome any barriers they might encounter. The aim is to help people improve their quality of life and avoid unplanned hospital admissions.

Care Coordinators act as a central point of contact to ensure that patients receive the best possible care, and the person is supported to achieve the outcomes that are important to them. This is achieved by bringing together all the information about a person's 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.

Main duties of the job

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Coordinate multidisciplinary meetings across local care organisations including identifying patients in need of review and collating any information required to facilitate their review prior to the meeting.

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Provide admin support to multidisciplinary meetings including taking minutes.

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Utilise GP Practice clinical systems (SystmOne and EMIS) and population health data to proactively identify relevant cohorts of patients to deliver personalised care

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Support patients within these cohorts to access health checks and other health services including conducting blood pressure (BP) checks and phlebotomy (blood sample collection) where appropriate.

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Assist with the collection of clinical observations such as BP, pulse, oxygen saturation, and other basic health indicators to support patient monitoring.

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Support the PCN in improving overall patient care through promotion of services available to them locally within the PCN and the wider health system

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Liaise with other key stakeholders as needed for the collective benefit of the patient including but not limited to GPs, nurses, pharmacists and other support staff from within the PCN practices or from other provider organisations

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Communicate effectively and sensitively using language appropriate to the patient and their carer and their level of understanding

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To provide coordination and navigation for patients and their carers across health and social care services, where appropriate linking with social prescribers and other patient link workers in the PCN

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Work in partnership with key providers in the local community to enable improved access to services for patients

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Work with practices to support delivery of any national and local targets outlined in the GP contract

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Contacting patients to increase uptake in designated clinics such as vaccinations, cancer screening and health reviews. Identifying reasonable adjustments that can be made for vulnerable groups of patients, to provide a more suitable environment to deliver their care.

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Coordinating case load visits for reviews/vaccinations to support the clinical team.

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Undertake phlebotomy and BP monitoring as required to support early detection and management of health conditions.

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Undertake quality improvement audits to identify best practice or areas to improve and share learning across the PCN.

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Participate in PCN workshops/training sessions relevant to the Care Coordinator role.

Job Types: Full-time, Permanent

Pay: 27,485.00-30,162.00 per year

Benefits:

Company pension
Work Location: In person

Application deadline: 04/08/2025