Job summary We are seeking Care Co-Ordinator who will play a key coordinating role in Hawthorn & Merchiston PCN. Care coordinators provide extra time, capacity and expertise to ensure that appropriate support is made available to patients and that their needs are addressed. In particular supporting Nursing Home, Care home residents and housebound patients. They will help patients, and their families understand, manage and utilise personal care and support plans and contribute to increasing the number of patients with personal health budgets. Care Coordinators will work closely with Primary Care Network (PCN) and GP Practices to ensure patients receive coordinated care, which is responsive to their needs and designed in cooperation with patients, carers, and all supporting services. Tackling health inequalities is a major focus for the PCN. This role will ensure that this key priority is embedded within all work carried out by the Care Coordinator team, who will provide much needed advice and guidance to a diverse population of patients. This role aims to give patients and their carers more control over their own health and care, achieve greater collaboration between GPs and their teams and community services, strengthen joint working with local partners, and improve health outcomes and tackle health inequalities. Main duties of the job The Care Coordinator will work as an integral part of the multi-disciplinary team supporting patients with multiple and complex needs and their carers to take an active and informed role within their own health care and wellbeing. They will provide a point of contact for the patient and their family/carers. They will work closely with other services to ensure the provision of seamless and integrated support. With the use of Clinical Systems and engagement with PCNs, Practices, and care homes, actively identify a caseload of patients who are in need of a care package at a designated surgery. Work directly with patients, their carers and advocates in line with best practice, to develop a holistic personalised care and support plan that brings together all the patients identified care and support needs and reflects what matters most to them. Assist Care Home Nursing teams, patients and their carers to access support or interventions that improve their health and wellbeing and increase their knowledge, skills and confidence. Assist patients and their families to consider and record their wishes and preferences in regard to future care and treatment in the event of a deterioration when they are no longer able to make decisions for themselves. Identify, report and action any issues of concern relating to safeguarding and quality of care arising from working with patients and referring onwards as appropriate. About us Hawthorn & Merchiston PCN supports two practices. The Merchiston practice was established around 1860 in the village of Stratton-St-Margaret. Until the 1950s, Stratton was a small farming community and it still retains its separate identity, despite now being a suburb of Swindon. The Partnership moved from the original Doctors house into new purpose-built premises in 1992. Merchiston Surgery is the larger Practice with a raw patient list of 13,500 (13,700 weighted list) We are a teaching practice with 2 Education Supervisors, 1 Clinical Supervisor, supporting 3 Trainee GPs. Rated excellent by the Swindon GP QA Panel for our trainee placement. Hawthorn Medical Centre has 13000 patients in Swindon, and was this year rated "Good" by CQC. We are a successful training practice with previous trainees staying with us. We are a friendly, supportive and hardworking team; reflected by our shared values of caring for each other and our patients. We are committed to providing the highest quality of care for our patients and ensuring that our staff feel valued and motivated. There is a strong team ethos across the practice and have a friendly and relaxed working environment. The Practices are supported by several ARRS roles employed by Hawthorn & Merchiston PCN: Clinical Pharmacists Pharmacy Technicians First Contact Physiotherapists Shared Care Home nurses Repeat Prescription Administrators Date posted 17 February 2025 Pay scheme Other Salary £12.59 an hour Contract Permanent Working pattern Full-time, Flexible working Reference number A5777-25-0004 Job locations Merchiston Surgery Highworth Road Swindon Wiltshire SN3 4BF Hawthorn Medical Centre May Close Swindon SN2 1UU Job description Job responsibilities Care Co-ordination: Care Planning: Record, action and follow-up referrals and care packages agreed for all patients within the PCN, especially those discussed at internal MDT meetings. Working with clinicians within your allocated practice, service users/patients, their families and carers, co-design and deliver care plans and ensure that the actions set out are being followed up and evaluated and are coordinated around the needs of the service user. Ensure that all individual care plans remain up to date, that they are evaluated and revised as necessary, and that record keeping is completed as appropriate. Identifying vulnerable patients that require an integrated care team approach: Ensure that individual care plans are revised following key events such as hospital admission or discharge, significant improvements or deterioration of their condition or service user/patient/carer concerns. Liaise directly with other teams within the health and care sector e.g. Worcestershire Acute Hospitals Trust, Worcestershire Health and Care Trust, Worcestershire County Council on behalf of the clinical team to ensure that actions are followed up. Identify networks of local statutory voluntary and community support services that could be deployed to assist individuals to achieve optimum health and wellbeing. Develop positive relationships to coordinate effective and responsive packages of care for service users. Ensure good communication is maintained with neighbourhood teams, care home staff and other health care professionals to ensure appropriate support is provided to patients upon discharge. Act as the first port of call for service users/patients/their families as appropriate in your caseload. Make referrals to Social Prescribers and other services to patients identified as potentially benefitting from these services. Manage and ensure the completion of monitoring, evaluation and assessment processes for all appropriate and relevant services, so that all reporting requirements are met and submitted in line with relevant timescales and NHS Quality and Outcome Frameworks. Maintain and develop engagement with all practice and care home staff and encourage best practice. Job Summary: Take a leading role in developing integrated care for patients within the PCN Care Home Team. Work with GPs to identify, manage and prioritise a caseload of patients per needs and, where required and as appropriate, refer people back to other health professionals within the PCN. Act as a building block by cooperating with other service providers to share information, jointly plan care provide a streamlined, integrated service and reduce variations in service delivery in adherence with confidentiality and data protection legislation and data sharing agreements. Have mechanisms in place to engage with patients who are using the service and their carers. Using reflective working and continuous improvement practices work collaboratively with other health and care services to continuously improve, develop and evolve the service and the patient experience. Ensure at all times, service users experience support and contact that is user-friendly, accessible, responsive to individual needs, warm and professional. Job description Job responsibilities Care Co-ordination: Care Planning: Record, action and follow-up referrals and care packages agreed for all patients within the PCN, especially those discussed at internal MDT meetings. Working with clinicians within your allocated practice, service users/patients, their families and carers, co-design and deliver care plans and ensure that the actions set out are being followed up and evaluated and are coordinated around the needs of the service user. Ensure that all individual care plans remain up to date, that they are evaluated and revised as necessary, and that record keeping is completed as appropriate. Identifying vulnerable patients that require an integrated care team approach: Ensure that individual care plans are revised following key events such as hospital admission or discharge, significant improvements or deterioration of their condition or service user/patient/carer concerns. Liaise directly with other teams within the health and care sector e.g. Worcestershire Acute Hospitals Trust, Worcestershire Health and Care Trust, Worcestershire County Council on behalf of the clinical team to ensure that actions are followed up. Identify networks of local statutory voluntary and community support services that could be deployed to assist individuals to achieve optimum health and wellbeing. Develop positive relationships to coordinate effective and responsive packages of care for service users. Ensure good communication is maintained with neighbourhood teams, care home staff and other health care professionals to ensure appropriate support is provided to patients upon discharge. Act as the first port of call for service users/patients/their families as appropriate in your caseload. Make referrals to Social Prescribers and other services to patients identified as potentially benefitting from these services. Manage and ensure the completion of monitoring, evaluation and assessment processes for all appropriate and relevant services, so that all reporting requirements are met and submitted in line with relevant timescales and NHS Quality and Outcome Frameworks. Maintain and develop engagement with all practice and care home staff and encourage best practice. Job Summary: Take a leading role in developing integrated care for patients within the PCN Care Home Team. Work with GPs to identify, manage and prioritise a caseload of patients per needs and, where required and as appropriate, refer people back to other health professionals within the PCN. Act as a building block by cooperating with other service providers to share information, jointly plan care provide a streamlined, integrated service and reduce variations in service delivery in adherence with confidentiality and data protection legislation and data sharing agreements. Have mechanisms in place to engage with patients who are using the service and their carers. Using reflective working and continuous improvement practices work collaboratively with other health and care services to continuously improve, develop and evolve the service and the patient experience. Ensure at all times, service users experience support and contact that is user-friendly, accessible, responsive to individual needs, warm and professional. Person Specification Qualifications Essential GCSE grade A to C in Math & English IT literate to include Microsoft Word, Excel and Outlook Desirable Further education in Healthcare Qualified in Phlebotomy Experience Essential Experience working with people preferably in a health care setting. Experience in accurate record keeping Desirable Experience of working in a health care environment Experience in using SystmOne Person Specification Qualifications Essential GCSE grade A to C in Math & English IT literate to include Microsoft Word, Excel and Outlook Desirable Further education in Healthcare Qualified in Phlebotomy Experience Essential Experience working with people preferably in a health care setting. Experience in accurate record keeping Desirable Experience of working in a health care environment Experience in using SystmOne 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 Merchiston Surgery Address Merchiston Surgery Highworth Road Swindon Wiltshire SN3 4BF Employer's website https://www.merchistonsurgery.co.uk (Opens in a new tab)