PCN Care Coordinator in Wilmslow

The Care Coordinator plays a pivotal role within the Primary Care Network (PCN) and GP practices, ensuring that patients receive well-organised, person-centred, and proactive care. This role focuses on individuals with Serious Mental Illness (SMI), Learning Disabilities (LD), and those living with long-term or complex health needs, supporting coordination of health checks, reviews, and care planning across primary, community, and secondary care services. The postholder supports the PCN to deliver high-quality care in line with NHS England's Enhanced Services, QOF, and Integrated Neighbourhood Team objectives.

Main duties of the job

• This role supports the coordination and delivery of key health checks and long-term condition reviews across the GP practice and PCN.
• You will oversee SMI and Learning Disability annual health checks, ensuring core assessments are completed, follow-up actions arranged, and communication is accessible for patients, carers, and support teams.
• You will help organise reviews for diabetes, respiratory disease, hypertension, heart conditions, CKD, endocrine disorders, and frailty, including falls reviews, medication checks, and home visits for house-bound patients.
• The role also supports cancer care reviews, NHS Health Checks, screening programmes, contraception and women's health reviews, men's health awareness, and coordination of routine and seasonal immunisations.
• You will provide care coordination and navigation, acting as a point of contact for patients and carers, supporting post-discharge follow-up, and ensuring smooth transitions between primary, community, and secondary care.
• Working within multidisciplinary teams, you will help track and complete actions, support proactive case finding, and contribute to effective communication that promotes engagement and self-management.
• The role involves maintaining accurate clinical records, supporting QOF, DES, and IIF reporting, and contributing to audits and service improvement.
• You will work closely with GPs, nurses, HCAs, PCN staff, community mental health and LD teams, secondary care, and local voluntary sector partners.

About us

Bramhall and Cheadle Hulme Primary Care Network (PCN) is a thriving network of GP practices located in the Stockport area, committed to delivering high-quality, patient care. We aim to provide innovative and coordinated care, enhancing services for patients while promoting preventative healthcare and managing long-term conditions. Our network is built on strong collaboration between member practices, local health services, and community partners. By working closely together, we aim to streamline patient care and improve access to essential services.

Job responsibilities

• You will coordinate and support the delivery and follow-up of all key health checks within the GP practice and PCN.
• This includes managing Serious Mental Illness (SMI) annual health checks by tracking completion of all core elements such as blood pressure, BMI, blood tests, lifestyle screening, medication reviews, and side-effect monitoring.
• You will liaise with mental health services to ensure follow-up actions, including ECGs and vaccinations, and promote engagement through reminders and reasonable adjustments.
• For Learning Disability (LD) annual health checks, you will organise invitations and follow-up for patients aged 14+, ensuring physical, mental health, medication, and lifestyle assessments are completed, while working closely with LD teams, carers, and advocates to support accessible communication.
• You will support the scheduling and coordination of long-term condition reviews, including diabetes, respiratory conditions, hypertension, heart failure, CHD, CKD, thyroid disorders, and other endocrine conditions.
• This also includes coordinating frailty assessments, falls reviews, medication checks, CGAs, and arranging home visits for housebound or care-home residents.
• You will assist with cancer care reviews, encourage participation in national screening programmes, support NHS Health Checks for adults aged 40-74, and monitor patients with raised cardiovascular risk.
• You will also help coordinate women's and men's health reviews, including cervical screening, contraception, postnatal checks, menopause care, and prostate health, along with supporting routine and seasonal immunisation programmes.
• As part of supporting SMI Annual Health Checks, the post-holder will also undertake venipuncture (blood taking) once trained and deemed competent, ensuring timely completion of required blood tests.
• The role includes a commitment to completing any additional clinical training needed to support safe, effective patient care for example training related to physical health monitoring, ECG support, or other relevant skills in line with service needs.
• Ongoing development will be encouraged to enhance the quality of assessments carried out during SMI reviews and other health checks.
• The role involves providing care coordination and navigation for patients and carers, ensuring smooth transitions between hospital, community, and practice teams, managing post-discharge follow-up and medication reconciliation, and escalating concerns to clinical staff when required.
• You will work collaboratively within multidisciplinary team meetings, track agreed actions, and support proactive case-finding for high-risk or complex patients.
• Effective communication with patients, carers, and professionals is essential, including use of accessible formats and promoting self-management and shared decision-making.
• You will maintain accurate clinical records using EMIS, support QOF, DES, and IIF monitoring and reporting, and contribute to audits and service improvement work.
• Key working relationships include GP practice teams, PCN colleagues, community mental health and LD teams, secondary care services, and voluntary and community organisations.

Person Specification

• Experience in health, social care, or community services
• Understanding of SMI, LD, and long-term conditions
• Excellent communication and interpersonal skills
• Ability to manage a caseload and prioritise workload
• Compassionate, patient-centred approach
• Experience in primary care or PCN settings
• Knowledge of NHS frameworks (QOF, DES)
• Familiarity with EMIS/SystmOne
• Training in care navigation or personalised care
• Awareness of safeguarding and equality legislation

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.

Salary: £27,485 to £29,758 a year. Salary dependent on skills and experience.