Care Coordinator: Mental Health, Care Home and Cancer Care

Job description

Job responsibilities

Key Responsibilities:

Work in line with PCN-directed priorities, supporting practice and network objectives.

Support delivery of QOF, DES, LES and other contractual requirements, ensuring appropriate coordination, recording, and follow-up.

Liaise with Care Coordinators and relevant leads across the PCN to share learning and develop best practice.

Proactively identify and support defined patient cohorts, using EMIS searches, Population Manager, and agreed decision-support tools.

Maintain regular and consistent communication with the lead GP(s) regarding patient progress, risks, or unmet needs.

Liaise with patients registered and usual GPs to ensure agreed actions are completed.

Act as the first point of contact for patients in Care Homes or on the care coordination caseload in relation to their care.

Coordinate care through direct liaison with multi-agency partners, including community services, mental health services, and social care.

Refer patients to PCN Social Prescribing Link Workers where appropriate.

Support patient and carer engagement, including collating feedback on experiences to inform service improvement.

Help people to manage their needs by answering queries, providing reassurance, and facilitating access to services.

Provide coordination and navigation for patients and carers across health and care services, working closely with other primary care roles.

Contribute to the development of the Care Coordinator role within the practice and support consistent, reliable processes.

Maintain strong engagement with all practice staff and encourage best practice.

Support national screening programmes to improve uptake and reduce inequalities.

Complete all mandatory and role-specific training.

Undertake other reasonable duties commensurate with the role.

Mental Health aspects of the role:

Use EMIS Population Manager and patient searches to identify patients requiring review, contact, or follow-up.

Work with the Lead GP and Clinical Pharmacist to support delivery of care requirements for patients on the SMI register, including agreed QOF/DES processes.

Develop, operate, and maintain call/recall systems for SMI patients to support timely care delivery and accurate recording.

Act as a link between patients, carers, the practice, social prescribing, and other services, escalating concerns appropriately.

Support continuity by ensuring follow-up actions are completed and clearly documented.

Care Home aspects of the role:

Develop and maintain relationships with Care Home Managers and senior staff as a named point of contact for general coordination queries, medications, and visit requests.

Provide a link between residents/carers, practice, community teams, and other services.

Support regular ward rounds and virtual ward rounds with named GPs for each care home, ensuring:

- Coordination of schedules and lists

- Information gathering in advance

- Accurate recording of outcomes

- Follow-up of agreed actions

Work closely with the Nurse Manager and practice nursing team to support residents with long-term conditions.

Run and act on agreed searches/reports to identify gaps in:

- Care plans and reviews

- RESPECT forms / advance care planning documentation

- Monitoring requirements

- Medication reviews (in liaison with the Clinical Pharmacist)

Coordinate plans with the named GP(s), nursing team and pharmacist to address identified gaps.

Support development of additional coordination pathways as agreed (e.g., frailty/deterioration tracking in care homes; cancer pathway navigation; targeted screening and inequality-focused outreach), in line with PCN priorities and capacity

Cancer Care Coordination aspects of the role:

The post holder will contribute to cancer early diagnosis and cancer care coordination activity aligned to PCN/practice priorities, including (where applicable) participation in the Humber and North Yorkshire Cancer Incentive Scheme.

Work with the PCN Clinical Cancer Lead (GP) and practice leadership to ensure cancer-related actions are coordinated and progressed.

Support implementation of practice/PCN processes that improve timeliness and completeness of:

- Urgent Suspected Cance (2WW) referral tracking

- Follow-up of investigations (e.g., FIT, imaging, blood tests where relevant)

- Time-bound safety-netting

- Communication with patients who have outstanding actions

Support the review and improvement of practice safety-netting systems, particularly for:

- Vague or low-risk symptoms

- Persistent symptoms after negative tests

- Patients with repeated presentations

Support screening uptake initiatives, including:

- Identifying patients with missing/unclear screening status or contact details

- Supporting targeted messaging/letters/texts to patients entering new screening cohorts

- Working with the team to address inequalities in uptake (e.g., LD/SMI groups)

Support improvements in smoking status recording by:

- Running searches to identify missing smoking status

- Coordinating opportunistic prompts and messaging processes

- Liaising with social prescribing / cessation support routes where appropriate

Liaise with PCN and Cancer Alliance contacts (as directed) to support reporting completeness, sharing of resources, and coordination of cancer-related improvement activities.

Note: The Care Coordinator does not provide clinical advice about cancer symptoms or referrals. Any clinical concerns identified during coordination activity must be escalated promptly to the responsible GP/clinical team.

Person Specification

Skills and personal qualities

Essential

• Ability to organise, plan and prioritise on own initiative, including meeting deadlines when under pressure.
• Ability to communicate effectively, both verbally and in writing, with people, their families, carers, partner agencies and stakeholders including the delivery of training, representing PCN at meetings, taking minutes, writing protocols .
• Ability to work within practice policies, protocols and scope boundaries both individually and as part of a team.
• Ability to maintain effective working relationships and to promote collaborative practice with all colleagues in PCN and the wider system.
• Ability to identify risk and assess/manage risk when working with individuals.
• Ability to support people in a way that inspires trust and confidence.
• Advanced experience of using word, excel and PowerPoint including ability to use word processing skills, emails and the internet to create simple plans and reports.
• Creative problem solver and willing to search for hard-to-find information.

Experience

Essential

• Experience of supporting people, their families and carers in a related role (including volunteering/unpaid work).
• Experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field (including unpaid work).
• Experience of data collection and providing monitoring information to assess the impact of services.
• Experience of driving change forward within safe systems through accurate tracking, follow-up and documentation.
• Experience of partnership/collaborative/multi-disciplinary working and of building relationships across a variety of organisations.

Desirable

• Experience of using EMIS Web, SystmOne or other clinical systems.

Knowledge and understanding

Essential

• Knowledge of the personalised care approach.
• Understanding of confidentiality, data protection and safeguarding.

Desirable

• Knowledge/familiarity with medical terminology.
• Knowledge of general practice clinical systems, preferably EMIS Web.

Qualifications

Essential

• NVQ Level 3 or related qualification.
• Evidence of professional and personal development, showing commitment to improve skills and abilities in new areas of work.

General

Essential

• Access to own transport and ability to travel across the locality on a regular basis.

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.

Employer details

Employer name

Eastgate Medical Group

Address

37 Eastgate

Hornsea

East Yorkshire

HU18 1LP

Employer's website

https://www.eastgatemedicalgroup.nhs.uk (Opens in a new tab)