Care Co-ordinator in Northampton

As a Care Coordinator within Royal Parks Primary Care Network (PCN), you will play a key role in supporting patients to access the right health, social care, and community services to meet their individual needs. Working as part of a multidisciplinary team, you will help coordinate care for patients, particularly those with long-term conditions, complex health needs, frailty, or those requiring support from multiple agencies.

You will act as a central point of contact for patients, carers, GP practices, and partner organisations, ensuring that care is well-organised, joined up, and focused on achieving the best possible outcomes. Through building strong relationships and providing personalised support, you will empower patients to take a more active role in managing their health and wellbeing.

The Primary Care Network (PCN) Care Coordinator plays a vital role in supporting patients to navigate health and care services, ensuring they receive the right care at the right time. Working collaboratively with GP practices, multidisciplinary teams, community services, and external agencies, the Care Coordinator helps to identify patient needs, coordinate care plans, and improve access to appropriate health and wellbeing support.

The post holder will proactively support individuals, particularly those with long-term conditions, complex health needs, frailty, or social care requirements, to manage their health and achieve better outcomes. They will act as a central point of contact for patients, carers, and healthcare professionals, helping to reduce barriers to care and improve the patient experience.

The Care Coordinator will contribute to the delivery of personalised care, supporting the wider objectives of the PCN by promoting integrated working, reducing health inequalities, and enhancing continuity of care across services. Strong communication, organisational skills, and the ability to build effective relationships with patients and partner organisations are essential for success in this role.

Royal Parks PCN serves a patient population of approximately 31,000 people across its member practices, enabling the network to deliver services at scale while maintaining strong links with local communities.

A patient care co-ordinator (PCC) may be required to deal with patients and, if appropriate, their carer, before or after the patients consultation with a clinician or other healthcare professional. Working closely with the patient and their clinician or other healthcare professional, the PCC co-ordinates patients healthcare and directs them to the appropriate service to ensure that they get the most suitable care from whatever health or social care provider is appropriate.

The PCCs role requires them to be able to work with, and understand the roles of, a variety of different people working in the practice and across the PCN including doctors, nurses, healthcare assistants, social prescribing link workers, physiotherapists, physician associates, paramedics, health and wellbeing coaches, podiatrists, occupational therapists and pharmacy technicians.

They may be given a caseload of identified patients and be required to ensure that their changing needs are addressed by taking into account local priorities, health inequalities and/or population health management risk stratification.

In addition to the induction process at The Royal Parks, where you will be provided with a full induction programme, when attending any practice within the network you will also be required to complete their practice induction programme. Whilst across the PCN we aim to standardise this process, inevitably there will be nuances particular to each practice. In any such instance, the practice management team will support you with this.

The effective use of training and development is fundamental in ensuring that all staff are equipped with the appropriate skills, knowledge, attitude and competences to perform their role. All staff will be required to partake and complete mandatory training as directed by the Lead Practice Manager. It is an expectation for this post holder to assess their own learning needs and undertake learning as appropriate.

The post holder will undertake mentorship for team members and disseminate learning and information gained to other team members in order to share good practice and inform others about current and future developments (e.g. courses and conferences). The post holder will provide an educational role to patients, carers, families and colleagues in an environment that facilitates learning.

All staff are to recognise the significance of collaborative working and understand their own role and scope and identify how this may develop over time. Staff are to prioritise their own workload and ensure effective time-management strategies are embedded within the culture of the team. Teamwork is essential in multidisciplinary environments and the post holder is to work as an effective and responsible team member, supporting others and exploring the mechanisms to develop new ways of working.

Effective communication is essential and all staff must ensure they communicate in a manner which enables the sharing of information in an appropriate manner. All staff should delegate clearly and appropriately, adopting the principles of safe practice and assessment of competence. Plans and outcomes by which to measure success should be agreed.

All staff should use technology and appropriate software as an aid to management in the planning, implementation and monitoring of care and presenting and communicating information. Data should be reviewed and processed using accurate SNOMED/read codes in order to ensure easy and accurate information retrieval for monitoring and audit processes.

Staff will be given detailed information during the induction process regarding policy and procedure. The post holder must adhere to the information contained within PCN and local practice policies and regional directives, ensuring protocols are adhered to at all times.

The following are the core responsibilities of the PCC. There may be, on occasion, a requirement to carry out other tasks. This will be dependent upon factors such as workload and staffing levels and the availability of a social prescribing link worker within the PCN:

• Receive and collate information from transfers of care (including hospital admissions and discharges) plus out of hours calls and present this information to the MDT as required.
• Liaise with service providers and clinicians to identify frequent flyers, and new service users utilising risk stratification tools provided and present this information to the bi-weekly MDT meetings.
• Support the completion of new referrals by checking criteria, and where criteria have been met, direct referral to the MDT.
• Signpost team members, service users and carers to relevant services.
• Overall responsibility for arranging the bi-weekly PCN led MDT meetings (including the weekly virtual Care Home(s) MDT) and the smooth running of integrated care within the team setting.
• Coordinate and manage the administrative functions of MDT meetings.
• Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function.
• Take minutes of MDT meetings and disseminate; chase progress against actions identified in these meetings and ensure follow up where necessary.
• Manage reporting required and associated within the DES specifications for required services.

Demonstrates ability to work as a member of a team. Is able to recognise personal limitations and refer to more appropriate colleague(s) when necessary. Actively work toward developing and maintaining effective working relationships both within and outside the PCN. Liaises with other stakeholders as needed for the collective benefit of patients including but not limited to Patients GP, Nurses, other practice staff and other healthcare professionals including pharmacists and pharmacy technicians from provider and commissioning organisations.

Work with service users, PCN practices and partners e.g. Care Homes to ensure new referrals are logged and allocated. Develop excellent working relationships with all partners, wider service networks including the voluntary sector, GP practices, adult social care, hospitals, community pharmacists and other members of the MDT. Acting as a point of contact for residents, families and professionals who visit the care home, such as MDT members and in-reach specialists.

Meet regularly with the clinical lead and review case load and MDT function. Keep the MDT and Royal Parks organisation abreast of good news stories. Provide background information about individuals for the bi-weekly MDT meetings. Communicate effectively with service users and their families/carers, other staff both internal and external and members of the public. Manage and prioritise workload on a daily basis and deal with the competing demands of the MDT.

To act at all times in an anti-discriminatory manner. To be able to plan and respond to workload according to operational priorities. To support the delivery of these functions across wider locality areas where necessary. To undertake any training required in order to maintain competency including mandatory training. To contribute to, and work within a safe working environment.

The Care Coordinator must at all times carry out duties and responsibilities with due regard to the GP Practices equal opportunity policies and procedures. The Care Coordinator is expected to take responsibility for self-development on a continuous basis, undertaking on-the-job training as required. The Care Coordinator must be aware of individual responsibilities under the Health and Safety at Work Act, and identify and report as necessary any untoward accident, incident or potentially hazardous environment.

Communicate effectively and sensitively and use language appropriate to a patient and carer/relatives condition and level of understanding. Effectively use all methods of communication and be aware of and manage barriers to communication. Effectively recognise and manage challenging behaviours, carers and or relatives. Provide information to patients, their carers and/or relatives on behalf of the team.

Be the point of liaison for service users and interface with all health and social care professionals, including keeping everyone informed and updated. Follow through actions identified by the MDT including arranging tests, referrals, signposting, etc. Follow through with service users and others involved to ensure all services and care arrangements are in place.

The post holder will be required to work within clearly defined organisational protocols, policies and procedures.

In addition to the primary responsibilities, the PCC may be requested to support delivery of QOF, incentive schemes, QIPP and other quality or cost effectiveness initiatives. To co-ordinate our Mental Health checks. To maintain our Carers award and work towards Gold. To maintain our veterans list. To liaise with our Safeguarding lead and follow up on any discharges from hospitals. To work with the GPs and build a relationship with the care homes to ensure patient care.

Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner. Duties may vary from time to time without changing the general character of the post or the level of responsibility.

The Successful candidate will be based at Langham Place Surgery.

Essential: Knowledge of System One, Knowledge of GP surgery.

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.