PCN MDT and Integrated Care Coordinator in London

South One PCN Newham is seeking an experienced MDT Coordinator, Care Coordinator and Integrated Care Lead to deliver proactive, integrated care for patients with long‐term conditions (LTCs). The role will coordinate Multi‐Disciplinary Team (MDT) working and ensure effective clinical care coordination across services, improving patient outcomes and reducing health inequalities.

Key responsibilities

• Alternate and support effective MDT meetings across the PCN, ensuring they are well structured, outcome focused and aligned with QOF requirements.
• Provide clinical coordination for patients with complex, long‐term conditions, ensuring timely follow‐up and continuity of care.
• Act as a central link between primary care, community services, social care and voluntary organisations.
• Support identification and proactive management of patients with high levels of need.
• Ensure personalised care plans are developed, implemented, and reviewed.
• Promote integrated, person‐centred care that addresses physical, mental and social needs.
• Contribute to reducing health inequalities and improving access for underserved populations.
• Monitor MDT activity and contribute to quality improvement and performance reporting.
• Support delivery and assurance of LTC Proactive Care QOF requirements.

Job responsibilities

• Coordinate and optimise MDT working, including organising meetings at practice, neighbourhood, PCN, RPN or borough levels.
• Ensure MDT meetings focus on high‐need patients, produce clear actions and ownership, and are documented and tracked.
• Coordinate care for patients discussed within MDTs, ensuring timely follow‐up of agreed actions.
• Act as a central point of coordination between primary care, community services, social care and voluntary sector partners.
• Support navigation of patients through complex care pathways, reducing fragmentation and improving continuity.
• Ensure personalised care plans are implemented, reviewed and updated in collaboration with MDT members.
• Identify gaps in care and escalated concerns appropriately.
• Support proactive management of patients at risk of deterioration, admission or poor outcomes.

Identification and proactive management of LTC patients

• Support identification and prioritisation of patients with multiple LTCs, frailty or high risk.
• Ensure MDT discussions focus on high‐risk and complex cohorts in line with QOF indicators.
• Facilitate development and review of proactive, personalised care plans.

Person‐centred and integrated care

• Enable MDTs to deliver holistic, person‐centred care planning covering physical, mental and social needs.
• Promote shared decision making and continuity of care.
• Ensure MDT actions translate into coordinated and effective care delivery across the PCN.

Effective MDT working and professional collaboration

• Facilitate collaboration between primary care, community services, social care and voluntary sector organisations.
• Ensure appropriate professional representation within MDTs.
• Promote integrated ways of working to reduce duplication and improve patient experience.

Health inequalities and targeted support

• Ensure MDT and care coordination activity targets patients with health inequalities or barriers to access.
• Support production of evidence demonstrating improvement in patient outcomes and service delivery.
• Align work with prevention, early intervention and neighbourhood priorities.

Quality, outcomes and continuous improvement

• Monitor MDT activity and care coordination against LTC proactive care QOF indicators.
• Support collection of evidence demonstrating improvement in patient outcomes and service delivery.
• Use data, feedback and learning to drive continuous improvement.

Governance, reporting and assurance

• Support delivery assurance for the LTC Proactive Care QOF within South One PCN.
• Provide reporting to PCN leadership, RPN and ICB.
• Act as a key point of contact for MDT and care coordination‐related performance matters.

Person specification

Qualifications – Essential

• Educated to degree level or equivalent experience in a relevant field (healthcare management, public health, nursing, allied health professional or social care).
• Evidence of continuous professional development relevant to integrated care, care coordination or service delivery.
• Strong working knowledge of NHS systems, primary care or community care environments.

Qualifications – Desirable

• Professional qualification in a health or social care discipline (e.g. nursing, AHP, social work).
• Training or certification in quality improvement methodologies (e.g. QI, PD, Lean).
• Knowledge or training related to long‐term condition management, population health or integrated care.
• Understanding of the LTC Proactive Care or similar NHS frameworks.

Experience – Essential

• Experience working in a PCN setting.
• Knowledge of LTC Proactive Care QOF or similar frameworks.
• Experience in quality improvement methodologies.
• Understanding of population health approaches.

Experience – Desirable

• Experience delivering proactive, coordinated care.
• Strong clinical care coordination improving patient pathways and experience.
• Improved outcomes for patients with long‐term conditions.
• Reduction in health inequalities across the PCN population.

Disclosure and Barring Service Check

This post requires a Disclosure and Barring Service check under the Rehabilitation of Offenders Act (Exceptions Order) 1975.

Salary

£25,000 to £35,000, depending on experience.