Job summary An exciting opportunity to support an innovative, collaborative and dynamic Primary Care Network, serving a population of over 80K patients, one of the largest in North West London (NWL) ICS. You will work operationally with the Senior PCN Development Manager, Digital and Transformation Lead and Social Prescribing Link Worker to drive forward key patient initiatives across our 7 practices within our local neighborhood team. Developing excellent working relationships with key system stakeholders, primary care leadership and practice managers across our PCN will be pivotal to the role. Our PCN is well respected across Harrow Place Based Partnership (PBP) and NWL ICS for providing good patient care and engaging local communities, with strong Patient Association co-production. Established experiencing working within the NHS, healthcare, social or voluntary sector would be desirable, although other candidates may be considered, depending on merit and skill set. Main duties of the job You must be able to work independently with minimal guidance and use your initiative to deal with a wide variety of queries and requests from the PCN leadership team, using enhanced engagement skills to build strong relationships with key contacts including community organisations, neighbourhood leads, health development coordinators and locality leads to ensure you are working with and as a vital part of an evolving wider view of health and social care in a community setting. Main duties of the job We are looking to recruit to the post of care coordinator, to work within our Primary Care Network. The successful candidate will play a key role in proactively identifying and working with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services. They will work closely with GPs and practice teams, supporting them to understand and manage their condition and ensuring their changing needs are addressed. They will enable people to access the support required to meet their health & wellbeing needs, helping to improve peoples quality of life. They will work alongside social prescribing link workers and health and wellbeing coaches to enable people navigate through the health and care system. The postholder will support the PCN management with conducting searches on data cohorts and helping to meet Impact and Investment Fund (IIF) indicators and Enhanced Service workstream targets. The successful candidate will have excellent interpersonal and communication skills, and be organised, patient and empathetic. They will have experience of working in health, social care or other support roles including direct contact with people, families or carers. About us About Healthsense PCN: Over 80K patients, one of the largest in NWL ICS. 7 strong Practices, all CQC-rated Outstanding or Good. Weekly PCN meetings, chaired by the PCN Clinical Directors. Our PCN leadership works collaboratively with system partners across Harrow PBP and NWL ICS. Practice Managers across the PCN are experienced and supportive, working collaboratively with PCN management. Date posted 14 February 2025 Pay scheme Other Salary £25,000 to £28,000 a year Contract Permanent Working pattern Full-time, Part-time, Flexible working Reference number A4162-25-0000 Job locations Pinn Medical Centre 37 Love Lane Pinner Middlesex HA5 3EE Enderley Road Centre 45 Enderley Road Harrow Middlesex HA3 5HF The Medical Centre 255 Eastcote Lane Harrow Middlesex HA2 8RS The Ridgeway Surgery 71 Imperial Drive Harrow Middlesex HA2 7DU Roxbourne Medical Centre 37 Rayners Lane Harrow Middlesex HA2 0UE Job description Job responsibilities Post: PCN Care Coordinator Salary: £25 28,000 (inclusive of London Weighting) Hours: 37.5 Hours Accountable To: Senior PCN Development Manager Location: Across the Healthsense PCN practices Purpose of the role Care coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services. They work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed. This is achieved by bringing together all the information about a persons identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person. Care coordinators review patients needs and help them access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers, health and wellbeing coaches, and other professionals where appropriate. Care coordinators could potentially provide time, capacity and expertise to support people in preparing for or following-up clinical conversations they have with primary care professionals to enable them to be actively involved in managing their care and supported to make choices that are right for them. Their aim is to help people improve their quality of life. The successful candidate will be based in a local cluster of General Practices as part of Healthsense Primary Care Network (PCN). They will be caring, dedicated, reliable and person-focused and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills. They will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing people, their families and carers with high quality support. This role is intended to become an integral part of the PCNs multidisciplinary team, working alongside social prescribing link workers and health and wellbeing coaches to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN. There may be a need to work remotely depending on the requirements of the role. Please note that the role of a care coordinator is not a clinical role. Key responsibilities The postholder will support the PCN management with conducting searches on data cohorts and helping to meet Impact and Investment Fund (IIF) indicators and Enhanced Service workstream targets. Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes. Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care. Assist people to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health. Support people to take up training and employment, and to access appropriate benefits where eligible; for example, through referral to social prescribing link workers. Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support. Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN. Support the coordination and delivery of multidisciplinary teams with the PCN. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations. Explore and assist people to access a personal health budget where appropriate. Work with people, their families, carers and healthcare team members to encourage effective help-seeking behaviours; Identify unpaid carers and help them access services to support them; Conduct follow-ups on communications from out of hospital and in-patient services; Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the persons circumstances. Key Tasks 1. Enable access to personalised care and support a. Take referrals for individuals or proactively identify people who could benefit from support through care coordination; b. Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs; c. Work towards increasing patients understanding of how to manage and develop health and wellbeing through offering advice and guidance; d. Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them; e. Use tools to measure peoples levels of knowledge, skills and confidence in managing their health and to tailor support to them accordingly. f. Work with the wider PCN, MDTs, and the social prescribing service to look at how carers can support people - this could include the initial identification of carers onto the carer register g. Support people to develop and implement personalised care and support plans; h. Review and update personalised care and support plans at regular intervals; i. Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes; 2. Coordinate and integrate care a. Making and managing appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations b. Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through wider the health and care system; c. Refer onwards to social prescribing link workers and health and wellbeing coaches where required; d. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported; e. Actively participate in multidisciplinary team meetings f. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns. g. Record what interventions are used to support people, and how people are developing on their health and care journey; h. Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation; i. Work sensitively with people, their families and carers to capture key information, while tracking of the impact of care coordination on their health and wellbeing; j. Encourage users to provide feedback and to share their stories about the impact of care coordination on their lives; k. Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service. 3. Professional development a. Work with a named clinical point of contact for advice and support. b. Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required; c. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety. 4. Miscellaneous a. Establish strong working relationships with GPs and practice teams and work collaboratively with other care coordinators, social prescribing link workers and health and wellbeing coaches, supporting each other, respecting each others views and meeting regularly as a team; b. Act as a champion for personalised care and shared decision making within the PCN; c. Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner; d. Identify opportunities & gaps in the service and provide feedback to continually improve the service and contribute to business planning; e. Work in accordance with the practices/PCNs policies and procedures; f. Contribute to the wider aims and objectives of the PCN to improve and support primary care. Job description Job responsibilities Post: PCN Care Coordinator Salary: £25 28,000 (inclusive of London Weighting) Hours: 37.5 Hours Accountable To: Senior PCN Development Manager Location: Across the Healthsense PCN practices Purpose of the role Care coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services. They work closely with GPs and practice teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers; supporting them to understand and manage their condition and ensuring their changing needs are addressed. This is achieved by bringing together all the information about a persons identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person. Care coordinators review patients needs and help them access the services and support they require to understand and manage their own health and wellbeing, referring to social prescribing link workers, health and wellbeing coaches, and other professionals where appropriate. Care coordinators could potentially provide time, capacity and expertise to support people in preparing for or following-up clinical conversations they have with primary care professionals to enable them to be actively involved in managing their care and supported to make choices that are right for them. Their aim is to help people improve their quality of life. The successful candidate will be based in a local cluster of General Practices as part of Healthsense Primary Care Network (PCN). They will be caring, dedicated, reliable and person-focused and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills. They will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing people, their families and carers with high quality support. This role is intended to become an integral part of the PCNs multidisciplinary team, working alongside social prescribing link workers and health and wellbeing coaches to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN. There may be a need to work remotely depending on the requirements of the role. Please note that the role of a care coordinator is not a clinical role. Key responsibilities The postholder will support the PCN management with conducting searches on data cohorts and helping to meet Impact and Investment Fund (IIF) indicators and Enhanced Service workstream targets. Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes. Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care. Assist people to access self-management education courses, peer support, health coaching and other interventions that support them in their health and wellbeing, and increase their levels of knowledge, skills and confidence in managing their health. Support people to take up training and employment, and to access appropriate benefits where eligible; for example, through referral to social prescribing link workers. Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support. Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN. Support the coordination and delivery of multidisciplinary teams with the PCN. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations. Explore and assist people to access a personal health budget where appropriate. Work with people, their families, carers and healthcare team members to encourage effective help-seeking behaviours; Identify unpaid carers and help them access services to support them; Conduct follow-ups on communications from out of hospital and in-patient services; Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the persons circumstances. Key Tasks 1. Enable access to personalised care and support a. Take referrals for individuals or proactively identify people who could benefit from support through care coordination; b. Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs; c. Work towards increasing patients understanding of how to manage and develop health and wellbeing through offering advice and guidance; d. Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them; e. Use tools to measure peoples levels of knowledge, skills and confidence in managing their health and to tailor support to them accordingly. f. Work with the wider PCN, MDTs, and the social prescribing service to look at how carers can support people - this could include the initial identification of carers onto the carer register g. Support people to develop and implement personalised care and support plans; h. Review and update personalised care and support plans at regular intervals; i. Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes; 2. Coordinate and integrate care a. Making and managing appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations b. Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through wider the health and care system; c. Refer onwards to social prescribing link workers and health and wellbeing coaches where required; d. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported; e. Actively participate in multidisciplinary team meetings f. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns. g. Record what interventions are used to support people, and how people are developing on their health and care journey; h. Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation; i. Work sensitively with people, their families and carers to capture key information, while tracking of the impact of care coordination on their health and wellbeing; j. Encourage users to provide feedback and to share their stories about the impact of care coordination on their lives; k. Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service. 3. Professional development a. Work with a named clinical point of contact for advice and support. b. Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required; c. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety. 4. Miscellaneous a. Establish strong working relationships with GPs and practice teams and work collaboratively with other care coordinators, social prescribing link workers and health and wellbeing coaches, supporting each other, respecting each others views and meeting regularly as a team; b. Act as a champion for personalised care and shared decision making within the PCN; c. Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner; d. Identify opportunities & gaps in the service and provide feedback to continually improve the service and contribute to business planning; e. Work in accordance with the practices/PCNs policies and procedures; f. Contribute to the wider aims and objectives of the PCN to improve and support primary care. Person Specification Qualifications Essential Demonstrable commitment to professional and personal development is enrolled in, undertaking or qualified from appropriate training as set out in the core curriculum by the Personalised Care Institute. Proficient in MS Office and web-based services. Desirable NVQ Level 3 in adult care - advanced level or equivalent qualifications or working towards it. Experience Essential Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity). Experience of working within multi-professional team environments. Experience of supporting people, their families and carers in a related role. Experience of data collection and using tools to measure the impact of services. Desirable Experience of working directly in a care coordinator role, adult health and social care, learning support or public health /health improvement. Experience or training in personalised care and support planning. Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation Personal qualities and attributes Essential Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way. Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity. Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders. Ability to identify risk and assess / manage risk when working with individuals. Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the care coordinator role e.g. when there is a mental health need requiring a qualified practitioner. Ability to maintain effective working relationships and to promote collaborative practice with all colleagues. Ability to demonstrate personal accountability, emotional resilience and work well under pressure. Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines. High level of written and verbal communication skills. Ability to work flexibly and enthusiastically within a team or on own initiative. Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety. Person Specification Qualifications Essential Demonstrable commitment to professional and personal development is enrolled in, undertaking or qualified from appropriate training as set out in the core curriculum by the Personalised Care Institute. Proficient in MS Office and web-based services. Desirable NVQ Level 3 in adult care - advanced level or equivalent qualifications or working towards it. Experience Essential Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity). Experience of working within multi-professional team environments. Experience of supporting people, their families and carers in a related role. Experience of data collection and using tools to measure the impact of services. Desirable Experience of working directly in a care coordinator role, adult health and social care, learning support or public health /health improvement. Experience or training in personalised care and support planning. Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation Personal qualities and attributes Essential Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way. Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity. Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders. Ability to identify risk and assess / manage risk when working with individuals. Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the care coordinator role e.g. when there is a mental health need requiring a qualified practitioner. Ability to maintain effective working relationships and to promote collaborative practice with all colleagues. Ability to demonstrate personal accountability, emotional resilience and work well under pressure. Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines. High level of written and verbal communication skills. Ability to work flexibly and enthusiastically within a team or on own initiative. Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety. 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 Healthsense PCN Address Pinn Medical Centre 37 Love Lane Pinner Middlesex HA5 3EE Employer's website https://www.thepinn.co.uk (Opens in a new tab)