Job responsibilities
Accountable to: PCN Clinical Lead and PCN Business Manager
Salary: £13.50-14.50 per hour (dependent on experience)
Working hours: 30-34 hours per week
Interview date: week commencing 15 September 2025
Job Summary
The Care
Coordinator will be part of the Primary Care Network (PCN) which is responsible
for managing the care of people registered with practices in the PCN. A key
part of the role of a care coordinator is in the Care Homes Multi-Disciplinary
Team (MDT), improving the continuity of care by acting as a point of contact
for residents, families and professionals who visit care homes. This will
involve coordinating the work of healthcare professionals and non-clinical
staff including volunteers and third sector agencies involved in the care of
registered patients.
In this
patient facing role the post holder will also be responsible for a caseload of
patients identified through the MDT meetings. Support provided directly with
patients and their carers would include co-producing personalised plans,
utilising decision aids, providing information and training opportunities,
making appointments, coordination and navigation for people and their carers
across health and care services.
The post
holder will contribute to tackling inequalities in health and social care
particularly regarding individuals with long-term conditions. An ethos of
promotion of independence and partnership-working is integral to this post.
Primary duties and areas of responsibility:
- To
take part in arranging the weekly PCN led MDT meetings (including the weekly
ward/home rounds) and the smooth running of integrated care within the team
setting. A key role of the Care Coordinator will be to schedule the weekly MDT
meetings, manage the meeting agenda items, ensuring that all new referrals are
identified, and information circulated to team members in advance of the
meeting.
- Take
minutes of MDT meetings and disseminate, chase progress against actions
identified in these meetings and ensure follow up where necessary.
- Manage a
caseload of patients identified through the MDT.
- Support
patients to utilise decision aids in preparation for a shared decision-making
conversation.
- Holistically
bring together all of a persons identified care and support needs and explore
options to meet these within a single personalised care and support plan
(PCSP), in line with PCSP best practice, based on what matters to the person.
- Help
people to manage their needs through answering queries, making and managing
appointments, and ensuring that people have good quality written or verbal
information to help them make choices about their care.
- Identify
the training needs of care home staff and escalate to the care home team or
relevant professional appropriately.
- Utilise
population health intelligence, which may include AI and related tools, to
proactively identify and work with a cohort of patients to deliver personalised
care.
- Receive
and collate information from transfers of care (including hospital admissions
and discharges) plus out of hours calls and present this information to the MDT
as required.
- Liaise
with service providers and clinicians to identify high service users, and new
service users utilising risk stratification tools provided and present this
information to the weekly MDT meetings.
- Support
the completion of new referrals by checking criteria, and where criteria have
been met, direct referral to the MDT.
- Signpost
team members, service users and carers to relevant services.
- Liaise
with other stakeholders as needed for the collective benefit of patients
including but not limited to Patients GP, Nurses, other practice staff and
otherhealthcare professionals including pharmacists and pharmacy technicians from
provider and commissioning organisations.
- Act as a
point of contact for residents, families, carers and professionals who visit
the care home, such as MDT members and in-reach specialists.
- Meet
regularly with the clinical lead and review case load and MDT function.
- Communicate
effectively with service users and their families/carers and provide
coordination across health and care services working closely with social
prescribing link workers, health and wellbeing coaches, and other primary care
professionals.
- Manage
and prioritise workload on a daily basis and deal with the competing demands of
the MDT.
- Act at
all times in an anti-discriminatory manner.
- Undertake
any training required in order to maintain competency including mandatory
training.
- Communicate
effectively and sensitively and use language appropriate to a patient and
carer/relatives condition and level of understanding.
- Be the
point of liaison for service users and interface with all health and social
care professionals, including keeping everyone informed and updated.
- The
post holder will be required to work within clearly defined organisational
protocols, policies and procedures.
- The
post-holder must comply at all times with the PCN member practice Health and
Safety policies, in particular by following agreed safe working procedures and
reporting incidents using the practice Incident Reporting System.
- The
post-holder will comply with the Data Protection Act (1984), The General Data
Protection Regulations (2018) and the Access to Health Records Act (1990).
- The
post-holder must co-operate with all policies and procedures designed to ensure
equality of employment. Co-workers, patients and visitors must be treated
equally irrespective of gender, ethnic origin, age, disability, sexual
orientation, religion etc.
- The
post-holder should always respect patient confidentiality and not divulge
patient information unless sanctioned by the requirements of the role.
- The
post-holder is required to travel independently between practice sites and to
attend meetings etc. hosted by other agencies.
- The post holder must have access to a car as travel between sites across the Taunton area will be required.
Job Description Agreement
The job description is intended as a basic guide to the scope and responsibilities of the post and its not exhaustive. It will be subject to regular review and amendment as necessary in consultation with the post holder.
