Job summary
Aylesbury Central Primary Care Network
Starting salary From:£23,965.50 WTE dependant on experience
Working hours:37.5 hours per week, part time considered minimum of 27.5 hours per week. Working 1 Saturday per month 09:00- 12:00
NHS Pension
33 days annual leave inclusive of bank holidays WTE
Employee Assistance Programme 24/7 Support
Do you enjoy working with the wider community and feel passionate about the quality of care and services patients receive? Are you currently working in a healthcare, social care, or support role and looking to take the next step in developing your skills within GP practices?
An exciting opportunity has arisen for aCare Coordinatorto join a well-established, growing and committed Primary Care Network (PCN) team. This role will support the delivery of enhanced care and services across the PCN patient population, with a particular focus on vulnerable patients and those living in residential and nursing home settings.
You will join a thriving multidisciplinary team, working alongside GPs, Care Coordinators, Social Prescribing Link Workers and other primary care professionals to deliver high-quality, patient-centred care.
Main duties of the job
Role Overview
As a Care Coordinator, you will play a key role within the PCN multidisciplinary team (MDT), supporting patients to navigate health and care services and ensuring their needs are met in a coordinated and personalised way. You will work proactively with a defined caseload of patients, their carers, care homes and external agencies to ensure appropriate support is in place and responsive to changing needs.
Essential Skills and Experience
- Experience working directly in healthcare, social care or support roles.
- Strong verbal and written communication skills, with a compassionate and patient-centred approach.
- Excellent organisational and time-management skills, with the ability to prioritise and multitask.
- Strong administrative skills with a keen eye for detail.
- Proficient in Microsoft Office (Word, Excel, PowerPoint) and digital systems such as Microsoft Teams.
- Ability to analyse, record and report data accurately.
- Understanding of confidentiality, safeguarding and information governance requirements.
This is an excellent opportunity for a motivated and collaborative individual who is passionate about improving patient outcomes and delivering coordinated, holistic care within primary care.
About us
About our PCN
Aylesbury Central Primary Care Network (PCN) is a collaborative partnership of 2 GP practices Berrycroft Community Health Centre, Whitehill Surgery working together to improve access, enhance patient care, and deliver integrated services to the community of central Aylesbury. The PCN was established on 1st July 2019, previously known as the BMW PCN.
These practices together serve a combined patient population of approximately 40,000 patients across the central Aylesbury area.
About FedBucks
As a GP Federation and Social Enterprise, we are proud to represent our member practices and to champion primary care by working with local general practice and system partners in the provision of community-based healthcare services. We are dedicated to providing safe and compassionate care to our patients across our range of planned and unplanned healthcare services in Buckinghamshire and believe in continuous commitment to quality service delivery and positive patient outcomes.
Patients are at the heart of everything we do, and we pride ourselves in our purpose when enabling excellent patient care and supporting general practice.
FedBucks is committed to safeguarding and promoting the welfare of children, young people, and vulnerable adults. All staff are expected to share this commitment and to uphold the organisations safeguarding policies and procedures at all times.
Job description
Job responsibilities
Key Responsibilities
- Use population health intelligence to proactively identify and support a cohort of patients.
- Act as a key point of contact, advocate and information resource for patients, carers, care teams and community services.
- Maintain regular communication with care homes regarding patient progress.
- Support shared decision-making by helping patients use decision aids and understand their care options.
- Develop and maintain personalised care and support plans (PCSPs) based on what matters to the patient.
- Support patients with appointment management, queries and access to high-quality written or verbal information.
- Visit patients in the community, at home or in care home settings to assess and discuss care needs.
- Support patients to access training, employment opportunities and appropriate benefits where eligible.
- Assess and support patient activation levels using tools such as the Patient Activation Measure.
- Assist with identifying high-risk patients and maintaining workload registers.
- Enable access to self-management education, peer support and wellbeing interventions.
- Coordinate care across health and social care services, working closely with social prescribing and wellbeing teams.
- Make referrals and signpost patients to appropriate services.
- Support MDT coordination, including diary management, meeting organisation and report preparation.
- Liaise across all PCN practices to support effective communication.
- Maintain patient confidentiality and comply with safeguarding, GDPR and organisational policies.
Job description
Job responsibilities
Key Responsibilities
- Use population health intelligence to proactively identify and support a cohort of patients.
- Act as a key point of contact, advocate and information resource for patients, carers, care teams and community services.
- Maintain regular communication with care homes regarding patient progress.
- Support shared decision-making by helping patients use decision aids and understand their care options.
- Develop and maintain personalised care and support plans (PCSPs) based on what matters to the patient.
- Support patients with appointment management, queries and access to high-quality written or verbal information.
- Visit patients in the community, at home or in care home settings to assess and discuss care needs.
- Support patients to access training, employment opportunities and appropriate benefits where eligible.
- Assess and support patient activation levels using tools such as the Patient Activation Measure.
- Assist with identifying high-risk patients and maintaining workload registers.
- Enable access to self-management education, peer support and wellbeing interventions.
- Coordinate care across health and social care services, working closely with social prescribing and wellbeing teams.
- Make referrals and signpost patients to appropriate services.
- Support MDT coordination, including diary management, meeting organisation and report preparation.
- Liaise across all PCN practices to support effective communication.
- Maintain patient confidentiality and comply with safeguarding, GDPR and organisational policies.
Person Specification
Skills and Knowledge
Essential
- Understanding of and commitment to equality diversity and inclusion
- Knowledge of policies and procedures including confidentiality safeguarding long working information governance and health and safety
Desirable
- Knowledge of how the wider NHS works including PCNs
- Knowledge of long term conditions and the complexities involved medical physical emotional and social
Qualifications
Essential
- GSCE or above in Maths and English
Desirable
- Higher level qualification such as NVQ in adult care Level 3
- Qualification relevant to health or social care
Personal Qualities and Attributes
Essential
- Ability to actively listen empathise with people and provide personalised support in a non judgemental way
- Ability to provide a culturally sensitive service supporting patients from all backgrounds and communities respecting lifestyles and diversity
- Ability to support people in a way that inspires trust and confidence motivating others to reach their potential
- Ability to communicate effectively with a wide variety of people
- Ability to identify risk and assess manage risk when working with individuals
- Willingness to work flexible hours when required to meet work demands
- Prepared to travel to patients homes if required
Desirable
- Proficient speaker of another language other than English
Experience
Essential
- Experience of working in health, social care and other support roles in direct contact with people, families or carers
- Experience of working in a multi-professional team environment
- Confident in using Email and sound IT knowledge
- Good written English and excellent record keeping skills
Desirable
- Experience of working in primary care
- Experience of working as a care coordinator
- Experience or training in personalised care and support planning
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation
- Proficient in use of Emis
- Experience of working with reports in Emis
Person Specification
Skills and Knowledge
Essential
- Understanding of and commitment to equality diversity and inclusion
- Knowledge of policies and procedures including confidentiality safeguarding long working information governance and health and safety
Desirable
- Knowledge of how the wider NHS works including PCNs
- Knowledge of long term conditions and the complexities involved medical physical emotional and social
Qualifications
Essential
- GSCE or above in Maths and English
Desirable
- Higher level qualification such as NVQ in adult care Level 3
- Qualification relevant to health or social care
Personal Qualities and Attributes
Essential
- Ability to actively listen empathise with people and provide personalised support in a non judgemental way
- Ability to provide a culturally sensitive service supporting patients from all backgrounds and communities respecting lifestyles and diversity
- Ability to support people in a way that inspires trust and confidence motivating others to reach their potential
- Ability to communicate effectively with a wide variety of people
- Ability to identify risk and assess manage risk when working with individuals
- Willingness to work flexible hours when required to meet work demands
- Prepared to travel to patients homes if required
Desirable
- Proficient speaker of another language other than English
Experience
Essential
- Experience of working in health, social care and other support roles in direct contact with people, families or carers
- Experience of working in a multi-professional team environment
- Confident in using Email and sound IT knowledge
- Good written English and excellent record keeping skills
Desirable
- Experience of working in primary care
- Experience of working as a care coordinator
- Experience or training in personalised care and support planning
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation
- Proficient in use of Emis
- Experience of working with reports in Emis
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.
