Job summary
An opportunity has arisen to recruit for Complex Health Coordinators for an exciting project which is happening in the South Peterborough Primary Care Network (SPPCN). The Horizontal Project aims to educate and to provide support to specific groups of patients with complex health needs who could benefit from additional support from us to improve their quality of life.
As a Complex Health Coordinator, you will work closely with GPs and other primary care professionals to identify and manage a caseload of patients with specific healthcare conditions, to ensure that their healthcare and social needs are being met, and to seek out and refer to appropriate local support service providers.
You will ideally have a background in healthcare coordination, and an understanding of projects and population health initiatives. In this role, you will be responsible for managing and coordinating care services, collaborating with multidisciplinary teams, and implementing processes to improve health outcomes for specific populations.
We welcome applicants from diverse backgrounds and experiences, and we believe that unique perspectives drive innovation. If you possess some, but not all, of the qualifications listed, we still encourage you to apply.
The candidate must be available to work on a full-time basis with flexibility when required to work across the five sites within the PCN.
This is a fixed term contract ending on 01 November 2025.
Main duties of the job
What you will do (not exhaustive)
- To work autonomously under the direction of a senior clinician(s) planning and prioritising own workload within the project which aims to target the populations identified within the Core 20 Plus 5 NHS approach.
- Work with individuals to support their personalized care needs and create care plans, following through on agreed actions and taking responsibility for supporting the individual to achieve their agreed goals.
- To be able to use clinical judgement to evaluate individuals difficulties and progress, including the recording and analysis of objective and subjective measurements.
- To effectively communicate and conduct assessment and discussions with patients, carers, clinicians, and colleagues using tact and persuasive skills in various settings.
- To be involved in the development, delivery, and evaluation of patient group work initiatives, in conjunction with a senior clinician, demonstrating initiative and curiosity about how to achieve positive patient outcomes through this therapeutic approach.
You will play a crucial role in the success of our population health project and contribute to enhancing the overall well-being of our community.
About us
LAKESIDE HEALTHCARE is changing the face of primary care provision in England. We are bold, adventurous and ambitious and determined to thrive in uncertain times. We are the largest true partnership in the NHS and operate from various sites across the East Midlands.
Caring & Respect: Simply put we genuinely care about people: working together for our patients and our teams, our patients come first in everything we do.
Teamwork & Quality: In all areas of our business we network, collaborate and learn from our Patients, Stakeholders and each another to ensure we are always striving to improve, making the right and best decisions to provide the best service.
South Peterborough PCN is a large, forward-thinking Primary Care Network compromising 4 practices across north Cambridgeshire and Peterborough.
We recognise the value that this role can bring to our practices and our patients, and we look forward to growing our PCN team. Our aim is to provide exemplary patient care; finding innovative solutions in general practice to deliver the best care we can to our patients.
South Peterborough PCN consists of 4 practices Lakeside Yaxley, Lakeside New Queen Street, Old Fletton Surgery and Wansford Surgery. For more information please visit https://www.england.nhs.uk/primary-care/primary-care-networks/
Job description
Job responsibilities
JOB TITLE: Complex Health Coordinator Horizontal Project
LOCATION: SP PCN Wansford and Kings Cliffe Surgery as main place of work.
JOB SUMMARY:
An exciting opportunity has arisen to recruit for Complex Health Coordinators for a project (Horizontal Project) that is being undertaken within the South Peterborough Primary Care Network (SPPCN). The aim of the Horizontal Project is to educate and to provide support to specific groups of patients who have been identified as those with complex health needs who could benefit from some additional input from Primary care to improve their quality of life.
The successful candidate will be responsible for conducting well-being and personalised care plan assessments for cohorts of patients with specific health conditions, in a variety of settings, using effective communication skills to support individuals with complex conditions to identify their next health and well-being steps, including referrals to appropriate service providers (both clinical and social).
They will require strong motivation and dedication to facilitate both individual and group work interventions to make health and well-being changes, seeking clinical advice when indicated.
They will need to be able to use clinical judgement to evaluate individuals difficulties and progress, including the recording and analysis of objective and subjective measurements.
They will need to work in a variety of settings, this includes lone working, with access to senior clinicians, according to protocols and reporting back patient progress and informing senior staff of any relevant issues.
DUTIES & AREAS OF RESPONSIBILITY
Patient Care
- To effectively communicate verbally with patients, carers, clinicians, and colleagues using tact and persuasive skills. This may involve using skills where patients have difficulties in communication e.g. Hearing loss, diminished sight, mental health issues, speech problems, cognitive impairment, behavioural problems, and pain. Conduct assessments and discussions about care needs in various settings, being mindful of confidentiality principles and risk issues.
- To maintain accurate patient records, (ensuring these are recorded on SystmOne clinical system within 24 hours) write letters, make onward referrals where indicated, using relevant systems, and ensuring a clearly documented rational for any action taken.
- Work with individuals to support their personalized care needs and create care plans, following through on agreed actions and taking responsibility for supporting the individual to achieve their agreed goals. To identify when patients need interventions from other services and initiate onward referral as indicated, within the GP practice team, third sector services, and including to the senior clinician(s) within the project.
- To be involved in the development, delivery, and evaluation of patient group work initiatives, in conjunction with a senior clinician, demonstrating initiative and curiosity about how to achieve positive patient outcomes through this therapeutic approach.
- To keep the individual at the centre of their wellbeing plan, raising awareness of shared decision making and provide information to help individuals make informed choices about their care.
- Support individuals in their health and wellbeing, including through self-management education, providing relevant resources and information, and accessing personal health budgets, training, employment, and benefits.
- Coordinate care services and work closely with other primary care roles.
- Assist with monitoring and actioning of referrals and communicate effectively with other practices in the network about this, to ensure timely management of referrals.
Project and Operational requirements
- To maintain integrity of Horizontal Project data in relevant system and provide written and verbal feedback regarding individual and group outcomes, generating report data to monitor project progress.
- Support and contribute to population health initiatives, including data analysis, and interpretation to identify trends and areas for improvement.
- To have knowledge of email, excel and Microsoft forms and clinical systems such as SystemOne or be willing to undergo training on these applications and any others as deemed relevant to the project delivery.
- Sound knowledge and awareness of population inequalities and health disparities affecting wellness and disease and the biopsychosocial factors that influence these, linking theory and models to clinical practise.
- Actively stay informed about developments in population health to improve project effectiveness, and share knowledge and resources within team, colleagues and within clinical role, including participating in delivery of training.
- Actively participate in the practice of supervision, keeping records and a portfolio to evidence skill and personal development.
- To attend relevant external and internal courses to extend knowledge or gain relevant skills to improve clinical practice as identified as part of the Appraisal process.
- Assist with all project documentation and timelines for successful execution of population health projects.
- Support the coordination and delivery of multi-disciplinary teams working within the network.
- To work effectively within the team structure, the PCN wider team and liaise appropriately with members of the project team and other agencies by attending project meetings, and case reviews. To inform/update all members of the multi-disciplinary team, service users and appropriate others of changes involving health and wellbeing, progress and other relevant matters that pertain to the support and well-being of the individual.
- Establish good working relationships with other practices in the network to facilitate effective teamwork and liaison, and to seek collaboration within project delivery.
- To plan and prioritise own workload.
- To support the development of the project outcomes and other staff within the team.
- To work autonomously under the direction of a senior clinician(s) within the project which aims to target the populations identified within the Core 20 Plus 5 NHS approach.
Other
- Be willing to undertake travel to various locations to carry out duties of the post.
- To safeguard the health, well-being, and safety of the patients we work with, some of whom maybe classed as vulnerable people or adults at risk. In the event of a risk to a Patient becoming apparent or if concerns arise about a vulnerable persons welfare, to immediately report these concerns in line with the appropriate policy and procedure.
NB. in addition to these responsibilities, employees are required to carry out such other duties as may be reasonably required. Lakeside Healthcare reserves the right to vary this job description from time to time in line with business needs.
Job description
Job responsibilities
JOB TITLE: Complex Health Coordinator Horizontal Project
LOCATION: SP PCN Wansford and Kings Cliffe Surgery as main place of work.
JOB SUMMARY:
An exciting opportunity has arisen to recruit for Complex Health Coordinators for a project (Horizontal Project) that is being undertaken within the South Peterborough Primary Care Network (SPPCN). The aim of the Horizontal Project is to educate and to provide support to specific groups of patients who have been identified as those with complex health needs who could benefit from some additional input from Primary care to improve their quality of life.
The successful candidate will be responsible for conducting well-being and personalised care plan assessments for cohorts of patients with specific health conditions, in a variety of settings, using effective communication skills to support individuals with complex conditions to identify their next health and well-being steps, including referrals to appropriate service providers (both clinical and social).
They will require strong motivation and dedication to facilitate both individual and group work interventions to make health and well-being changes, seeking clinical advice when indicated.
They will need to be able to use clinical judgement to evaluate individuals difficulties and progress, including the recording and analysis of objective and subjective measurements.
They will need to work in a variety of settings, this includes lone working, with access to senior clinicians, according to protocols and reporting back patient progress and informing senior staff of any relevant issues.
DUTIES & AREAS OF RESPONSIBILITY
Patient Care
- To effectively communicate verbally with patients, carers, clinicians, and colleagues using tact and persuasive skills. This may involve using skills where patients have difficulties in communication e.g. Hearing loss, diminished sight, mental health issues, speech problems, cognitive impairment, behavioural problems, and pain. Conduct assessments and discussions about care needs in various settings, being mindful of confidentiality principles and risk issues.
- To maintain accurate patient records, (ensuring these are recorded on SystmOne clinical system within 24 hours) write letters, make onward referrals where indicated, using relevant systems, and ensuring a clearly documented rational for any action taken.
- Work with individuals to support their personalized care needs and create care plans, following through on agreed actions and taking responsibility for supporting the individual to achieve their agreed goals. To identify when patients need interventions from other services and initiate onward referral as indicated, within the GP practice team, third sector services, and including to the senior clinician(s) within the project.
- To be involved in the development, delivery, and evaluation of patient group work initiatives, in conjunction with a senior clinician, demonstrating initiative and curiosity about how to achieve positive patient outcomes through this therapeutic approach.
- To keep the individual at the centre of their wellbeing plan, raising awareness of shared decision making and provide information to help individuals make informed choices about their care.
- Support individuals in their health and wellbeing, including through self-management education, providing relevant resources and information, and accessing personal health budgets, training, employment, and benefits.
- Coordinate care services and work closely with other primary care roles.
- Assist with monitoring and actioning of referrals and communicate effectively with other practices in the network about this, to ensure timely management of referrals.
Project and Operational requirements
- To maintain integrity of Horizontal Project data in relevant system and provide written and verbal feedback regarding individual and group outcomes, generating report data to monitor project progress.
- Support and contribute to population health initiatives, including data analysis, and interpretation to identify trends and areas for improvement.
- To have knowledge of email, excel and Microsoft forms and clinical systems such as SystemOne or be willing to undergo training on these applications and any others as deemed relevant to the project delivery.
- Sound knowledge and awareness of population inequalities and health disparities affecting wellness and disease and the biopsychosocial factors that influence these, linking theory and models to clinical practise.
- Actively stay informed about developments in population health to improve project effectiveness, and share knowledge and resources within team, colleagues and within clinical role, including participating in delivery of training.
- Actively participate in the practice of supervision, keeping records and a portfolio to evidence skill and personal development.
- To attend relevant external and internal courses to extend knowledge or gain relevant skills to improve clinical practice as identified as part of the Appraisal process.
- Assist with all project documentation and timelines for successful execution of population health projects.
- Support the coordination and delivery of multi-disciplinary teams working within the network.
- To work effectively within the team structure, the PCN wider team and liaise appropriately with members of the project team and other agencies by attending project meetings, and case reviews. To inform/update all members of the multi-disciplinary team, service users and appropriate others of changes involving health and wellbeing, progress and other relevant matters that pertain to the support and well-being of the individual.
- Establish good working relationships with other practices in the network to facilitate effective teamwork and liaison, and to seek collaboration within project delivery.
- To plan and prioritise own workload.
- To support the development of the project outcomes and other staff within the team.
- To work autonomously under the direction of a senior clinician(s) within the project which aims to target the populations identified within the Core 20 Plus 5 NHS approach.
Other
- Be willing to undertake travel to various locations to carry out duties of the post.
- To safeguard the health, well-being, and safety of the patients we work with, some of whom maybe classed as vulnerable people or adults at risk. In the event of a risk to a Patient becoming apparent or if concerns arise about a vulnerable persons welfare, to immediately report these concerns in line with the appropriate policy and procedure.
NB. in addition to these responsibilities, employees are required to carry out such other duties as may be reasonably required. Lakeside Healthcare reserves the right to vary this job description from time to time in line with business needs.
Person Specification
Qualifications
Essential
- NVQ Level 3 or equivalent and/or relevant basic/first level professional qualification
- Good level of education with GCSE Math and English Grade C or above (or equivalent)
Desirable
- Safeguarding level 3 in Adults & Children & Young People
Experience
Essential
- Experience of working with healthcare professionals and/or previous experience in the NHS or social care.
- Experience of using clinical systems.
- Experience coordinating with multiple stakeholder or individuals to meet specified outcomes.
- Experience of working in a face-to-face environment with patients, including providing advice/signposting, 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 including the voluntary sector.
Desirable
- Experience of using SystmOne
- Experience of group work and group dynamics theory
- Experience of supporting service improvement
Person Specification
Qualifications
Essential
- NVQ Level 3 or equivalent and/or relevant basic/first level professional qualification
- Good level of education with GCSE Math and English Grade C or above (or equivalent)
Desirable
- Safeguarding level 3 in Adults & Children & Young People
Experience
Essential
- Experience of working with healthcare professionals and/or previous experience in the NHS or social care.
- Experience of using clinical systems.
- Experience coordinating with multiple stakeholder or individuals to meet specified outcomes.
- Experience of working in a face-to-face environment with patients, including providing advice/signposting, 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 including the voluntary sector.
Desirable
- Experience of using SystmOne
- Experience of group work and group dynamics theory
- Experience of supporting service improvement
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
