Underwood Surgery

Care Coordinator

The closing date is 10 April 2026

Job summary

Care Coordinators play an important role within our PCN, working closely with our GP practice teams, Frailty Nurses, Social Prescribing Link Workers, and community services. They work together within the Frailty Team, identifying and managing a caseload of identified patients, making sure that appropriate support is made available to them and their carers. 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.

Main duties of the job

Undertake home visits to have supportive discussions with frail patients and their families, capturing their care and end of life wishes.

Liaise with the Frailty Nurses, GPs and Social Prescribers to ensure that patients are supported to stay well at home.

Undertake BP readings as part of wellbeing checks.

Develop strong relationships with Secondary Care, community and voluntary sector partners.

About us

Cheltenham Central PCN comprises five Practices in the heart of Cheltenham, and was awarded PCN of the Year in 2023. PCN staff enjoy supportive supervision, an open-door policy and an investment in staff wellbeing and progression.

Date posted

30 March 2026

Pay scheme

Other

Salary

£24,500 to £27,000 a year Dependent on experience

Contract

Permanent

Working pattern

Full-time, Flexible working

Reference number

A0438-26-0001

Job locations

139 St. Georges Road

Cheltenham

Gloucestershire

GL50 3EQ

Wilson Health Centre

236 Prestbury Road

Cheltenham

GL52 3EY

Job description

Job responsibilities

In coordination with the Frailty Team, undertake home visits to see patients in their homes, capturing their wishes and what matters to them.

Provide coordination and navigation, and support referrals for people and their carers across health and care services, working closely with community services and other members of the Primary Care team, helping to ensure patients receive a joined-up service and the most appropriate support.

Manage a caseload of referred patients approaching End of Life, and proactively identify a cohort of people in need of anticipatory care, using local knowledge and population health intelligence

Support the organisation, coordination and delivery of multidisciplinary teams (MDTs) with the PCN

Attend the MDTs and be the key person for ensuring regular attendance from nominated representatives or their deputies for each service

Ensure MDT actions are recorded appropriately and followed-up within the defined timescales agreed at the MDT meetings

Improve continuity of care by acting as a point of contact for patients, families and professionals, such as MDT members and in-reach specialists

Bring together a persons identified care and support needs and explore their options to meet these in a single personalised care and support plan

Ensure that people have good quality information to help them make choices about their care and structure conversations using a coaching approach