Tone Valley Primary Care Network

Care Coordinator for Proactive Care

The closing date is 20 November 2025

Job summary

We have an exciting and innovative new opportunity for a Care Co-ordinator working on the Proactive Care (PAC) project for Tone Valley Primary Care Network (PCN). The role involves working with a team of clinicians to enable people to live healthy independent lives and support active self-management and prevention. The candidate will possess excellent communication and organisation skills and have experience in a Health, Social Care or Educational background workplace.

The successful candidate will join our growing PCN workforce and support the delivery of care bringing together all the information about a patient's identified care and support needs and exploring options to meet these by identifying and signposting to appropriate clinicians. Patient needs will be discussed at MDT meetings with clear plans put into place to support people in our community.

Main duties of the job

Co-ordinators play an important role within a PCN to proactively identify and work with people to provide coordination and navigation of care and support across health and care services.

They work closely with GPs and practice teams to support patients in the community, acting as a central point of contact to ensure appropriate support is made available to them; supporting them to understand and manage their condition and ensuring their changing needs are addressed. This is achieved by bringing together all the information about a persons identified care and support needs with a clear action plan, based on what matters to the person and their family.

Care coordinators review patient's needs and help them access the services and support they require to understand and manage their own health and wellbeing, referring to voluntary sector services, mental health services, Village Agent services, social services, social prescribing link workers, health and wellbeing coaches, and other professionals where appropriate.

About us

Tone Valley PCN consists of 5 like-minded Somerset practices; Lyngford Park Surgery, Taunton Vale Healthcare, Creech Medical Centre, Warwick House Medical Centre, North Curry Health Centre and are responsible for the care of around 36,500 patients.

The successful candidate will be based in a local cluster of General Practices as part of Tone Valley PCN. They will be caring, dedicated, reliable and person-focused and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills. They will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing patients with high quality support. This role is intended to become an integral part of the PCN practices multidisciplinary teams, working alongside GPs, social prescribing link workers, village agents and health & wellbeing coaches to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN.

Travelling across all five Practices and sites is a requirement for this role.

Please note that the role of a care coordinator is not a clinical role.

Date posted

30 October 2025

Pay scheme

Other

Salary

Depending on experience Based on Band 4 AfC

Contract

Permanent

Working pattern

Full-time

Reference number

A3705-25-0001

Job locations

Creech Medical Centre

Hyde Lane

Creech St. Michael

Taunton

Somerset

TA3 5FA

Job description

Job responsibilities

Salary: based on indicative Agenda for Change Band 4

Interviews: expected to take place week commencing 24 November 2025 at Creech Medical Centre

Key responsibilities

The aim of Proactive Care is to provide proactive and personalised healthcare for people with multiple long-term conditions, including frailty and health inequalities delivered through multi-disciplinary teams in local communities.

Provide coordination and navigation for health, social care and neighbourhood services helping to ensure patients receive a joined-up service and the most appropriate support.

Working collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, and where appropriate, refer to other health professionals within the PCN.

Support the coordination and delivery of multidisciplinary teams with the PCN.

Carry out holistic assessments to aid patients in managing any long-term conditions they may have, supporting self-management and access to care.

Support people to understand their level of knowledge, skills and confidence (their 'Activation' level) when engaging with their health and wellbeing, self-management, engagement in education courses, peer support or interventions.

Support PCNs in developing communication channels between GPs and including in reaching into secondary care services and follow up post discharge.

Maintain accurate and timely records of referrals and interventions to enable monitoring and evaluation of the service.

Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the patient's circumstances.

Contribute to risk and impact assessments, monitoring and evaluations of the service.

Cross cover care-coordinators and administrative duties within the Proactive Care Team as required by the service.

Key Tasks

1. Enable access to personalised care and support:

a. Take referrals for individuals or proactively identify patients who could benefit from support through care coordination;

b. Support patients to develop and implement personalised care and support plans;

c. Review and update personalised care and support plans at regular intervals;

e. Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the patient's care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes;

2. Coordinate and integrate care:

a. Help to transition seamlessly between services and support them to navigate through the health and care system;

b. Refer onwards to appropriate health and social care professionals where required;

c. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the patient's care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported;

d. Actively participate in multidisciplinary team meetings in the PCN and individual practices as and when appropriate. This may include minuting and administrative tasks that arise from the meeting;

e. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals and highlighting any safety concerns.

f. Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation;

g. Encourage patients to provide feedback and to share their stories about the impact of care coordination on their lives;

h. Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service.

3. Professional development:

a. Work with a named clinical point of contact for advice and support;

b. Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required;

c. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.

4. Miscellaneous:

a. Establish strong working relationships with GPs and practice teams and work collaboratively with other care coordinators, social prescribing link workers and health and wellbeing coaches, supporting each other, respecting each others views and meeting regularly as a team;

b. Act as a champion for personalised care and shared decision making within the PCN;

c. Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner;

d. Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning;

e. Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities;

f. Work in accordance with the practices and PCNs policies and procedures

g. Duties may vary from time to time without changing the general character of the post or the level of responsibility

h. Contribute to the wider aims and objectives of the PCN to improve and support primary care.

i. To support in the delivery of the PCN Network DES, enhanced services and other service requirements on behalf of the PCN.

Job Description Agreement

This Job Description is flexible, and the post holder will be expected to undertake any other duties appropriate to the role as may be required by the PCN. This Job Description is subject to change from time to time with organisational need and the post holders agreement should not unreasonably be denied.