Job summary The Care Coordinator will work as a key part of the Primary Care Network (PCN) multi-disciplinary (MDT) team.Works closely with the GPs and other primary care professionals within the PCN to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed. Plays an integral role in facilitating the care home MDT, to improve the continuity of care by acting as a point of contact for residents, families and professionals.Contributes to tackling inequalities in health and social care. An ethos of promotion of independence, shared decision making, personalisation and partnership working is integral to this post. As the role evolves the care coordinator will undertake direct work with patients and families to develop personalised care plans. This role has the option to be a hybrid role with the option of 2 WFH days per week. Main duties of the job To work within the Care Home and Frailty team and support with administrative duties. Working with a variety of clinical roles which include, Advanced Clinical Practitioners, Registered Nurses, Paramedics & Occupational Therapists. About us Our Primary Care Network Preston Park PCN is a group of five surgeries - Beaconsfield Medical Practice, The Haven Practice, Preston Park Surgery, Stanford Medical Centre and Warmdene Surgery. We serve approximately 57,000 patients and aim to support and connect with our local community. Primary Care Networks (PCNs) bringGP practices together with other local services such as community, mental health, social care and the voluntary sector to look after local populations. PCNs will help to joinupservices at a local level, focusing on the specific needs of these local populations, with patients still accessing routine GP appointments as they do now. What are Primary Care Networks? PCNs build oncurrent primary care services and enable greater provision of proactive, personalised, coordinated and more integrated health and social care.Clinicians describe this as a change from reactively providing appointments to proactively providingcare for the people and communities they serve. Where emerging PCNs are in place in parts of the country, there are clear benefits for patients and clinicians. PCNs usually have a 30-50k population and are geographically contiguous (next to ortouchinganother). All GP practices in our area are expected tosign up to be a member of aPCN.You can read the NHS England PCN FAQs hereand view the BMAPCN handbook (March 2019) here. Date posted 04 February 2025 Pay scheme Other Salary £23,875 a year Contract Permanent Working pattern Full-time, Part-time, Flexible working, Home or remote working Reference number A5388-25-0001 Job locations Deneway Surgery Ground Floor Lions Dene, 11 The Deneway Brighton East Sussex BN1 5AZ Job description Job responsibilities Provide a first point of contact for patients and clinicians in coordinating patients care. Deal with incoming queries from patients and/or their carers and other healthcare providers. Encourage people, their families and carers to provide feedback and engage fully in the care coordination process. Ensure timely follow up and action for patients from communications from community and secondary care. Monitor tasks to ensure they are completed and care delivered through regular audit of the clinical system. Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers and other primary care professionals. Signpost and organise appointments, follow ups or other actions to help the PCN provide high quality, compassionate care to our patient population. Support the alignment of care homes to practices, including new patient registrations. Support the care home MDT with the weekly ward rounds through identification of people in need of review, collation of information on patients requiring MDT input. Also to provide coordination and administrative support to the MDT. Support the PCN in coordinating all key activities including access to services, advice and information, and ensuring health and care planning is timely, efficient and patient-centred. Support PCN staff and patients to be prepared to have shared-decision making conversations, including utilising decision aids and tools. Work collaboratively with other Care Coordinators across the PCN to share best practice. Work sensitively with patients, their families and carers to capture key information, enabling comprehensive and accurate records of support. Work with the PCN MDT to utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care. The list of duties in the job description should not be regarded as exclusive or exhaustive. There will be other duties and requirements associated with the job and the right to update the job description from time to time to reflect changes in or to the job. Job description Job responsibilities Provide a first point of contact for patients and clinicians in coordinating patients care. Deal with incoming queries from patients and/or their carers and other healthcare providers. Encourage people, their families and carers to provide feedback and engage fully in the care coordination process. Ensure timely follow up and action for patients from communications from community and secondary care. Monitor tasks to ensure they are completed and care delivered through regular audit of the clinical system. Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers and other primary care professionals. Signpost and organise appointments, follow ups or other actions to help the PCN provide high quality, compassionate care to our patient population. Support the alignment of care homes to practices, including new patient registrations. Support the care home MDT with the weekly ward rounds through identification of people in need of review, collation of information on patients requiring MDT input. Also to provide coordination and administrative support to the MDT. Support the PCN in coordinating all key activities including access to services, advice and information, and ensuring health and care planning is timely, efficient and patient-centred. Support PCN staff and patients to be prepared to have shared-decision making conversations, including utilising decision aids and tools. Work collaboratively with other Care Coordinators across the PCN to share best practice. Work sensitively with patients, their families and carers to capture key information, enabling comprehensive and accurate records of support. Work with the PCN MDT to utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care. The list of duties in the job description should not be regarded as exclusive or exhaustive. There will be other duties and requirements associated with the job and the right to update the job description from time to time to reflect changes in or to the job. Person Specification Experience Essential Minimum of 1 year of experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field Able to prioritise and manage own workload Able to work as part of a team Excellent interpersonal skills Excellent organisational and administration skills Experience of coordinating and liaising with multiple stakeholders or individuals to meet specified outcomes Experience handling confidential/sensitive information Experience of providing advice/signposting to service users Knowledge of Microsoft Office suite Desirable NVQ 3 or equivalent and/or relevant basic/first level professional qualification Experience of coproduction with patients or service-users Experience of using technology and digital tools to support health and wellbeing Knowledge of Information Governance and data quality Knowledge of medical patient systems Understanding of health and social care processes Person Specification Experience Essential Minimum of 1 year of experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field Able to prioritise and manage own workload Able to work as part of a team Excellent interpersonal skills Excellent organisational and administration skills Experience of coordinating and liaising with multiple stakeholders or individuals to meet specified outcomes Experience handling confidential/sensitive information Experience of providing advice/signposting to service users Knowledge of Microsoft Office suite Desirable NVQ 3 or equivalent and/or relevant basic/first level professional qualification Experience of coproduction with patients or service-users Experience of using technology and digital tools to support health and wellbeing Knowledge of Information Governance and data quality Knowledge of medical patient systems Understanding of health and social care processes 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 Preston Park Community PCN Limited Company Address Deneway Surgery Ground Floor Lions Dene, 11 The Deneway Brighton East Sussex BN1 5AZ Employer's website https://prestonparkcommunitypcn.gpweb.org.uk/ (Opens in a new tab)