Care Coordinator

Job description

Job responsibilities

MAIN DUTIES AND RESPONSIBILITIES

• Proactively identify people to support their personalised care requirements, using the available decision support aids.
• Telephone triage all incoming referrals to bring together all of a persons identified care and support needs, and explore their options to meet these via a single personalised care and support plan, or seamlessly refer cases, if necessary, to appropriate professionals.
• Help people to manage their needs, answering their queries and supporting them to make appointments or to take up training and employment, and to access appropriate benefits where eligible.
• Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing, including through use of the Patient Activation Measure.
• Raise awareness of shared decision making and decision support tools, and assist people to be more prepared to have a shared decision making conversation.
• Ensure that people have good quality information to help them make choices about their care,
• Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing.
• Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles.
• Maintain accurate records as required, including providing patient-related information for entering Clinical Reporting Systems, within the required time frame
• To be a point of contact for GP practices, MDT and Social Prescribing Link Workers, as well as a direct link for the wider system across the city.
• Support the identification of patients for inclusion in MDTs within PCNs.
• Support the collection of patient data for analysis of outcome measure for service interpretation and growth

Role Specific Key Tasks

Education

• Promote social prescribing across the PCN, Health & Social Care professionals and the wider system, including its role in self-management, addressing health inequalities and the wider determinants of health.

Referrals

• Receive and action referrals for social prescriptions via agreed systems.

Personalised Support

• Provide holistic, personcentred support by developing and reviewing personalised care plans, preparing people for shared decisionmaking, and helping them manage their health and wellbeing.
• Work proactively with diverse communities to ensure equal access to community, voluntary and statutory services, including selfmanagement and peer support.
• Follow up with individuals, gather feedback and outcomes, and contribute to service improvement within the PCN.

Community Asset Development

• Support the development and sustainability of community assets by working with VCSE organisations and local groups to ensure accessible, inclusive resources that meet diverse health and wellbeing needs.
• Build strong partnerships with community organisations to ensure safe, timely referrals and coordinated support for individuals.
• Gather feedback from community partners to understand capacity, gaps and opportunities, sharing insights with the PCN to inform service development.

Collaborative working

• Work as part of the PCN multidisciplinary team, building strong relationships with GP practices, social prescribing link workers, health coaches and other primary care professionals to deliver coordinated, personalised support.
• Support effective communication within the MDT by sharing timely updates, acting as a key contact across practices and partners, and ensuring smooth navigation for people with complex needs.
• Collaborate with VCSE organisations, local authority teams and community groups to improve access, reduce duplication and embed personalised care approaches across the system.
• Participate in MDT meetings, help identify individuals who may benefit from personalised care, and contribute to shared problem-solving and continuous improvement across the PCN and wider city.

Data Collection & Analysis

• Collect, record and analyse data to support personalised care and population health management, capturing key information about individuals needs, outcomes and experiences.
• Ensure accurate, timely documentation in clinical systems, following data protection and governance requirements.
• Analyse referral patterns, presenting needs and service use to identify trends, inequalities and gaps, sharing insights to inform decision-making and service development.
• Gather qualitative feedback and lived experience stories to support continuous improvement and strengthen community partnerships.

Professional Development

• Engage in ongoing professional development through supervision, training and skills development aligned with NHS Englands personalised care framework.
• Work with line managers to review performance, identify learning needs and set development goals.
• Maintain uptodate knowledge of local services, community resources and system developments, and complete all required organisational training.
• Participate in reflective practice, peer learning and knowledge sharing to support consistent, highquality personalised care across the MDT.

Service Development

• Contribute to the ongoing improvement of personalised care services by identifying gaps, opportunities and innovations with MDT colleagues and community partners.
• Use feedback, data and lived-experience insights to support responsive, person-centred service design and reduce health inequalities.
• Participate in quality improvement, business planning and coproduction of new initiatives.
• Promote consistent practice across PCNs through shared learning, collaboration and championing approaches that improve access, experience and outcomes.

Leadership

• Demonstrate leadership by supporting the development and delivery of high quality personalised care across the PCN.
• Act as a role model for person-centred, strengths based and community connected practice.
• Share learning, offer guidance and contribute to innovation, problem solving and service development.
• Uphold organisational values, promote equality and inclusion, and help foster a positive, supportive working culture.

Other

• Undertake additional duties consistent with the role and respond flexibly to service needs and organisational priorities.
• Support team resilience by adapting to changing demands and assisting colleagues when required.
• Adhere to all organisational policies, including confidentiality, safeguarding, information governance and professional conduct.
• Carry out any reasonable tasks requested by management that contribute to high quality personalised care and effective service delivery.

Confidentiality

• In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, Practice staff and other healthcare workers. All such information from any source is to be regarded as strictly confidential.
• Information relating to patients, carers, colleagues, other healthcare workers or the business of the Alliance may only be divulged to authorized persons in accordance with the Alliances policies and procedures relating to confidentiality, and the protection of personal and sensitive data.

Health & Safety

• The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the Alliances Health & Safety Policy to include:
• Identifying the risk involved in work activities and undertaking such activities in a way that manages those risks.
• Ensuring that all accidents or dangerous accidents are reported and investigated and follow up action taken where necessary.

Equality and Diversity

• The post-holder will support the quality, diversity and rights of patients, carers and colleagues to include:
• Acting in a way that recognizes the importance of peoples rights, interpreting them in a way that is consistent with current legislation.
• Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.
• Behaving in a manner which is welcoming to and of the individual, is non-judgemental and respects their circumstances, feelings, priorities and rights.

Quality

The post-holder will strive to maintain quality within the Alliance, and will:

• Alert other team members to issues of quality and risk.
• Assess own performance and take accountability for own actions, either directly or under supervision.
• Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhanced the teams performance.
• Work effectively with individuals in other agencies to meet patients needs.
• Effectively manage own time, workload and resources.

Communication

The post-holder should recognize the importance of effective communication within the team and will strive to:

• Communicate effectively with other team members.
• Communicate effectively with patients and carers.
• Recognise peoples needs for alternative methods of communication and respond accordingly.

Person Specification

Experience

Essential

• Ability to competently use technology and IT systems including word processing, email and the internet to create simple personalised plans with individuals
• Experience of supporting people, their families and carers in a paid or unpaid capacity
• Experience of working in a community setting
• Experience of handling confidential information.
• Experience of collecting and recording information and data
• Ability to identify risk to self and others, Identifying and reporting safeguarding incidents

Desirable

• Experience of working in or with voluntary organisations or groups in a paid or unpaid capacity
• Experience of working collaboratively with different organisations, building trust, confidence and partnerships
• Extensive knowledge of local services within a Sunderland locality through either living or working within one of the wider Sunderland settings.
• Experience of working with GPs and/or other Health or Social Care providers or knowledge of how systems work

Motivation and Skills

Essential

• Prioritise and work to deadlines.
• Outstanding organisational skills
• Work effectively and collaboratively as part of a team but also autonomously.
• High level and adaptable communication skills across a range individuals of all ages, backgrounds and cultures with varying social and emotional needs
• Able to respond to challenges with resilience and manage situations calmly and professionally.
• Passionate advocate for digital transformation in Primary Care
• Promote and maintain good working relationships with a variety of external partners.
• Keep accurate records of discussions and clearly replicate discussions in writing
• Work on own initiative but within constraints of the role
• Provide motivational coaching with the ability to inspire trust and confidence
• Confident and comfortable with difficult situations
• Able to work under pressure and emotionally resilient

Desirable

• Able to think creatively and use initiative to develop solutions to problems.
• Ability to support the development of small voluntary led groups
• Understanding the impact of economic and environmental factors on people's health and wellbeing

Other

Essential

• Understands the principles of equality and diversity.
• A firm commitment to CPD
• Full UK driving licence with use of own car
• Ability to travel across Sunderland if required
• Meet DBS standards and Criminal Record checks

Qualifications

Essential

• Demonstrable commitment to personal and professional development
• Proficient in the use of Microsoft Office applications.

Desirable

• PCI Accredited Tailored
• qualification in Care coordination (can be arranged if not in place)

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

Sunderland GP Alliance

Address

North East BIC

Wearfield

Sunderland

Tyne and Wear

SR5 2TA

Employer's website

https://www.sunderlandgpalliance.co.uk/ (Opens in a new tab)