Job summary An exciting opportunity has arisen for a Care Coordinator to join Dartford MODEL Primary Care Network as part of their growing multi-disciplinary team. We pride ourselves on providing excellent patient centred care and wish to expand our team to deliver high quality services across our network. Working in our established PCN team, alongside our two existing care coordinators, you will focus on supporting the practices with coordinating patients journeys through primary care. Main duties of the job The Care Coordinator will play an important role in supporting the PCN to coordinate all key activity including improving access to services, providing advice, and information, and ensuring health and care planning is timely, efficient, and patient-centered. The role will include supporting digital initiatives and includes responsibilities for the co-ordination of the patients journey through primary care. The post holder will work with the other members of the primary care team to support the management and decision making about care and service provision for individual patients.The Care Coordinator will play an important role in supporting the PCN to coordinate all key activity including improving access to services, providing advice, and information, and ensuring health and care planning is timely, efficient, and patient-centered. The role will include supporting digital initiatives and includes responsibilities for the co-ordination of the patients journey through primary care. The post holder will work with the other members of the primary care team to support the management and decision making about care and service provision for individual patients. About us Dartford MODEL PCN covers around 34,000 patients registered with Wellcome Practice, Dr Shimmins and partners (Dartford East) and Lowfield Medical Centre. Primary Care Networks (PCN) are groups of GP practices working closely together with other primary and community care staff and healthcare organisations to provide integrated services to their local populations. They work collectively to understand the health needs of their population and to deliver improvements to the quality of care in provided in primary care, care outside of hospital and across the PCNs. Date posted 12 March 2025 Pay scheme Other Salary £26,530 to £29,114 a year Dependent upon experience Contract Permanent Working pattern Full-time Reference number A5319-25-0003 Job locations Dartford West Health Centre Tower Road Dartford DA1 2HA Lowfield Medical Centre Lowfield Street Dartford DA1 1HP Dartford East Health Centre Pilgrims Way Dartford DA1 1QY Job description Job responsibilities Duties and responsibilities Work with our GPs and other primary care professionals in order to identify and manage a caseload of patients with specific needs, flagging any concerns to the relevant GP and referring to other health and social care professionals as appropriate. Utilise population health information to identify and work with high-risk patient populations and specific cohorts; such as the frail elderly, those with long term conditions, learning disabilities, those requiring palliative care or safeguarding concerns. Holistically bring together all of a persons identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person. Identify those elements of the care plan which require specialist input (pharmacist, dietician, nurse, medic etc) and ensure that these are completed in timely manner. Assist patients to access self-management education courses, peer support or interventions that support them in their health and wellbeing, providing relevant and up to date information and resources. Assist with coordinating clinics and recalls for flu, routine immunisations, health checks and other reviews. Code and log relevant information in EMIS. Participate in clinical governance activity and contribute to the improvement in quality of health outcomes through audit, risk management and Quality Improvement. Alerts other team members to concerns about risk, quality, and safety. Participates in investigation of incidents and events as required. Collects data for audit purposes and supports the use of clinical audit to monitor quality in the service. Contributes to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance. Effectively manages own time, workload, and resources. Meets timescales/deadlines for audits and written returns to ensure that the Practice meets quality standards and receives the designated funding. To link with and maintain good working relationships with colleagues in Kent County Council, Dartford Borough Council, Imago, Ellenor, HCRG, DGS and ADSS and other partners. Supporting practices with other patient groups as required Identifying patients with mild to moderate frailty that are living in their own homes. Working with patients and our partners, to identify the needs of this group. Managing referrals into the monthly Multi-Disciplinary Team meeting and actioning outcomes relating to the practices. Supporting the Enhanced Health in Care Homes DES. Supporting practices in maintaining a learning disabilities register and encouraging people on this register to attend the practice for an annual review. Assisting with the development of personalized care plans, including advanced care plans/treatment escalation plans. Developing links with organisations involved in the care of this group of patients, including Imago, ADSS, learning disability and community nursing teams and other health and social care partners. Working with other staff in the practices and PCN to facilitate the early diagnosis of cancer by promoting awareness of signs and symptoms, promoting national cancer screening programmes and ensuring systems are in place for the management and safety netting of suspected cancer investigations and referrals. Ensuring all patients with a new diagnosis of cancer are coded within the clinical system. o Inviting patients with a diagnosis of cancer to attend for a cancer care review and ensuring that they are signposted to services provided by partner organisations. Maintaining palliative care registers within the practice to support practices to deliver end of life care Developing links with organisations involved in the care of this group of patients, including Ellenor, Cancer Nurse Specialist, Imago, community nursing teams and other health and social care partners. It is expected that the Care Coordinators will work as a team to provide cross cover for periods of leave. Confidentiality In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately. In the performance of the duties outlined in the Job Description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the practice as business organisation. All such information from any source from any source is to be regarded as strictly confidential. Information relating to patients, carers, colleagues, other healthcare workers or the business of the practice may only be divulged to authorised persons in accordance with the practice 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 practice Health & Safety Policy to include: Using security systems within the workplace according to practice guidelines. Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks. Making effective use of training to update knowledge and skills. Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards and reporting potential risks identified. Equality and Diversity The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include: Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with practice procedures and policies, and 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. Personal/Professional Development The post-holder will participate in training programmes implemented by the PCN as part of this employment, such training to include: Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development. Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work. Quality The post-holder will strive to maintain quality within the practice, and will: Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance. Work effectively with individuals in agencies to meet patients needs. Effectively manage own time, workload and resources. Apply practice policies, protocols and guidance. Communication The post-holder should recognise the importance of effective communication within the team and will strive to: Communicate effectively with other team members, patients and carers. Recognise peoples needs for alternative methods of communication and respond accordingly. The post-holder will frequently be exposed to difficult or emotional situations as part of their work. This may include imparting unwelcome news to staff or patients, some of whom may be angry or distressed. It may also involve challenging members of the staff team on their behavior or poor performance. Working Conditions The post-holder will be required to use a computer regularly during the normal course of their duties. There is a requirement to travel to other practices within the PCN area, and to work related events or training within or outside the Dartford, Swanley and Gravesham area Job description Job responsibilities Duties and responsibilities Work with our GPs and other primary care professionals in order to identify and manage a caseload of patients with specific needs, flagging any concerns to the relevant GP and referring to other health and social care professionals as appropriate. Utilise population health information to identify and work with high-risk patient populations and specific cohorts; such as the frail elderly, those with long term conditions, learning disabilities, those requiring palliative care or safeguarding concerns. Holistically bring together all of a persons identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person. Identify those elements of the care plan which require specialist input (pharmacist, dietician, nurse, medic etc) and ensure that these are completed in timely manner. Assist patients to access self-management education courses, peer support or interventions that support them in their health and wellbeing, providing relevant and up to date information and resources. Assist with coordinating clinics and recalls for flu, routine immunisations, health checks and other reviews. Code and log relevant information in EMIS. Participate in clinical governance activity and contribute to the improvement in quality of health outcomes through audit, risk management and Quality Improvement. Alerts other team members to concerns about risk, quality, and safety. Participates in investigation of incidents and events as required. Collects data for audit purposes and supports the use of clinical audit to monitor quality in the service. Contributes to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance. Effectively manages own time, workload, and resources. Meets timescales/deadlines for audits and written returns to ensure that the Practice meets quality standards and receives the designated funding. To link with and maintain good working relationships with colleagues in Kent County Council, Dartford Borough Council, Imago, Ellenor, HCRG, DGS and ADSS and other partners. Supporting practices with other patient groups as required Identifying patients with mild to moderate frailty that are living in their own homes. Working with patients and our partners, to identify the needs of this group. Managing referrals into the monthly Multi-Disciplinary Team meeting and actioning outcomes relating to the practices. Supporting the Enhanced Health in Care Homes DES. Supporting practices in maintaining a learning disabilities register and encouraging people on this register to attend the practice for an annual review. Assisting with the development of personalized care plans, including advanced care plans/treatment escalation plans. Developing links with organisations involved in the care of this group of patients, including Imago, ADSS, learning disability and community nursing teams and other health and social care partners. Working with other staff in the practices and PCN to facilitate the early diagnosis of cancer by promoting awareness of signs and symptoms, promoting national cancer screening programmes and ensuring systems are in place for the management and safety netting of suspected cancer investigations and referrals. Ensuring all patients with a new diagnosis of cancer are coded within the clinical system. o Inviting patients with a diagnosis of cancer to attend for a cancer care review and ensuring that they are signposted to services provided by partner organisations. Maintaining palliative care registers within the practice to support practices to deliver end of life care Developing links with organisations involved in the care of this group of patients, including Ellenor, Cancer Nurse Specialist, Imago, community nursing teams and other health and social care partners. It is expected that the Care Coordinators will work as a team to provide cross cover for periods of leave. Confidentiality In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately. In the performance of the duties outlined in the Job Description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the practice as business organisation. All such information from any source from any source is to be regarded as strictly confidential. Information relating to patients, carers, colleagues, other healthcare workers or the business of the practice may only be divulged to authorised persons in accordance with the practice 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 practice Health & Safety Policy to include: Using security systems within the workplace according to practice guidelines. Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks. Making effective use of training to update knowledge and skills. Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards and reporting potential risks identified. Equality and Diversity The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include: Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with practice procedures and policies, and 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. Personal/Professional Development The post-holder will participate in training programmes implemented by the PCN as part of this employment, such training to include: Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development. Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work. Quality The post-holder will strive to maintain quality within the practice, and will: Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance. Work effectively with individuals in agencies to meet patients needs. Effectively manage own time, workload and resources. Apply practice policies, protocols and guidance. Communication The post-holder should recognise the importance of effective communication within the team and will strive to: Communicate effectively with other team members, patients and carers. Recognise peoples needs for alternative methods of communication and respond accordingly. The post-holder will frequently be exposed to difficult or emotional situations as part of their work. This may include imparting unwelcome news to staff or patients, some of whom may be angry or distressed. It may also involve challenging members of the staff team on their behavior or poor performance. Working Conditions The post-holder will be required to use a computer regularly during the normal course of their duties. There is a requirement to travel to other practices within the PCN area, and to work related events or training within or outside the Dartford, Swanley and Gravesham area Person Specification Experience Essential Previous work experiences in a healthcare setting Knowledge of the Personalised care approach Knowledge of the needs of patients with long term conditions Understanding of, and commitment to, equality, diversity and inclusion Knowledge of IT systems to include the ability to use word processing skills, emails and internet Experience in health promotion An appreciation of the nature of GPs and general practices Ability to build rapport and gain trust with patients Demonstrate the ability to communicate complex and sensitive information in an understandable form to a variety of audiences Ability to prioritise own workload, work under pressure and to tight deadlines Desirable Experience in a primary care setting Experience in project management or implementing new systems and processes Experience of working directly in a community development context, adult health and social care, learning support or public health/health improvement (can include unpaid work) Experience of supporting people, their families and carers in a related role (can include unpaid work) Experience of partnership/collaborative working and of building relationships across a variety of organisations including the voluntary sector Experience of using GP clinical systems e.g. EMIS Qualifications Essential Educated to GCSE or equivalent Demonstrable commitment to professional and personal development Desirable Additional qualification in health and social care Other Essential Evidence of recent and commitment to ongoing continuing professional development Ability to work on own initiative and as part of a team Ability to work within own limitations and refer to senior colleagues or GPs when appropriate Flexible and adaptable to work environment Ability to work under pressure and meet deadlines Good timekeeping Professional appearance Person Specification Experience Essential Previous work experiences in a healthcare setting Knowledge of the Personalised care approach Knowledge of the needs of patients with long term conditions Understanding of, and commitment to, equality, diversity and inclusion Knowledge of IT systems to include the ability to use word processing skills, emails and internet Experience in health promotion An appreciation of the nature of GPs and general practices Ability to build rapport and gain trust with patients Demonstrate the ability to communicate complex and sensitive information in an understandable form to a variety of audiences Ability to prioritise own workload, work under pressure and to tight deadlines Desirable Experience in a primary care setting Experience in project management or implementing new systems and processes Experience of working directly in a community development context, adult health and social care, learning support or public health/health improvement (can include unpaid work) Experience of supporting people, their families and carers in a related role (can include unpaid work) Experience of partnership/collaborative working and of building relationships across a variety of organisations including the voluntary sector Experience of using GP clinical systems e.g. EMIS Qualifications Essential Educated to GCSE or equivalent Demonstrable commitment to professional and personal development Desirable Additional qualification in health and social care Other Essential Evidence of recent and commitment to ongoing continuing professional development Ability to work on own initiative and as part of a team Ability to work within own limitations and refer to senior colleagues or GPs when appropriate Flexible and adaptable to work environment Ability to work under pressure and meet deadlines Good timekeeping Professional appearance 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 The Wellcome Practice Address Dartford West Health Centre Tower Road Dartford DA1 2HA Employer's website https://www.thewellcomepractice.nhs.uk/ (Opens in a new tab)