Job summary

Under the direction of the PCN team, a care coordinator will be required to undertake the following and will receive the relevant training and supervision to:

identify a cohort of patients who meet specific criteria as determined by the Service priority areas using population health intelligence;

Deliver personalised holistic healthcare and support in order to manage their needs proactively, exploring options or a single personalised care and support plan.

Provide advice, guidance and signpost to other services, co-ordinate patient care services and work with the care team to evaluate interventions

The core competencies required of a Care Co-ordinator are as follows and the specific duties and responsibilities are identified below.

Main duties of the job

The Care Coordinator will work as part of the PCN team to provide personalised, holistic support to patients, helping them to access appropriate care, services and support. Key duties will include:

Using population health intelligence to identify and proactively support cohorts of patients in line with service priorities and contractual requirements. Contacting patients to understand their individual needs, supporting shared decision-making and developing trusting, person-centred relationships. Supporting patients to manage their health and wellbeing by providing information, answering queries, coordinating appointments and helping them understand their care options.

Developing and supporting personalised care and support plans with patients and their families, ensuring records are accurate and kept up to date.

Navigating and signposting patients, carers and families to appropriate health, social care, community and voluntary sector services, working closely with social prescribing and other PCN roles.

Monitoring patient progress and recognising when additional or urgent support is required, escalating concerns appropriately to relevant professionals. Supporting access to self-management education, peer support, training, benefits and other interventions that promote health and wellbeing.

Supporting MDT meetings, including those relating to care homes, and assisting with vaccination programmes where required.

About us

Trinity Health Group is a PCN made up of four practices on the west of the district (Trinity Medical Centre, Maybush Medical Centre, Crofton and Sharlston Medical Practice and Warrengate Medical Centre). Our vision is that all our patients should have the same chance at a happy, healthy life. We believe that a sustainable, resilient Primary Care Service working collaboratively with volunteer and community services and social enterprise organisations supports this vision. Our Mission is to add years to the lives of our patients and to add life to those years.