Proactive Anticipatory Care (PAC) Neighborhood Care Coordinator

Job summary

The Proactive Anticipatory Care Neighbourhood Care Coordinator will support the delivery of personalised, proactive, and holistic care within the Primary Care Network. Working as part of a multidisciplinary team, the postholder will coordinate care for a defined caseload of patients, ensuring timely communication, collaboration, and follow-up across health, social care, and community services. Acting as a central point of contact for patients, families, and professionals, the Coordinator will facilitate effective anticipatory care planning, monitor outcomes, and promote continuity of care to improve health and wellbeing within the neighbourhood population.

Main duties of the job

To support the delivery of personalised, proactive, and holistic care within the Primary Care Network (PCN), working as part of a multidisciplinary team (MDT).

To be responsible for a caseload of patients aligned to a specific neighbourhood primary care team.

Ensure the right professionals are involved, notified and prepared for the meetings in advance.

Produce high quality notes following MDT meetings to include agreed and assigned actions.

Carry out home visits for assessment, monitoring, and delivery of care as appropriate.

Participate in the review of patient outcomes and goals over time.

Act as a central, continuous point of contact for the patient, their relatives/carers and the professionals involved in the care plan.

Collaborate with community teams, families, carers, and external partners to support coordinated care delivery.

Effectively signpost patients to appropriate health and wellbeing services that are best placed to meet unmet care needs.

Work collaboratively with the nursing team and social prescribing team within the PAC service and escalate patients who require more specialised input from those services when required.

Support the coordination and implementation of personalised care plans reflecting patient preferences, goals, and needs.

Refer or request referrals on patients behalf to appropriate services that can assist with meeting outstanding care needs.

About us

Sutton PCNs is the network of Sutton PCNs working together in Sutton and is also the local GP Federation. All GP practices in Sutton are shareholders (members) of the Sutton PCNs and our Board provides clear leadership through strong GP practice/PCN representation. Our mission is to work collaboratively with patients, practices, the emerging Primary Care Networks (PCNs) and staff to deliver consistently outstanding health and care services for all our communities.

As is the case elsewhere, Primary Care in Sutton is under extreme pressure. The challenge for Sutton PCNs is to work in partnership with our local ICB our four PCNs (and 24 practices) and the wider Integrated Care System in Southwest London to help shape and implement the transformation of Primary Care in Sutton to ensure that it can both survive and thrive while shifting to population health approaches to health and care.

The Sutton PCNs shape and deliver health care with our practices to improve patient outcomes. We have developed a comprehensive strategy for the development of the Sutton PCNs. The post holder will have a key role in supporting the development of our Extended Access and as such will be required to have significant experience of either primary care or development of small or emerging organisations. You'll be joining a great team in a great place, where your commitment will be genuinely valued, your skills respected, and your ambition rewarded.