Care Coordinator - Age Well

South Hambleton and Ryedale Primary Care Network; Easingwold; Hybrid; GBP 25,000 - 30,000; Full time

Job summary

A healthcare provider in Easingwold seeks a Care Coordinator to support older individuals within the ‘Age Well’ team. This role emphasizes preventive care and personalized support. The successful candidate will establish relationships with older patients, engage them in their care processes, and collaborate with a multidisciplinary team to improve health outcomes. Candidates should possess NVQ Level 3 in adult care or equivalent, and have strong communication and analytical skills. This position offers an opportunity to make a significant impact on community health.

Benefits

Comprehensive training opportunities

Supportive team environment

Professional development programs

Qualifications

• Strong commitment to professional and personal development.
• Candidates should have experience working directly with people in care roles.
• Knowledge of motivational interviewing or behavior change techniques is desirable.

Responsibilities

• Act as the first point of contact for older people in the Age Well pathway.
• Conduct comprehensive assessments to identify care needs.
• Develop personalised care and support plans based on individual needs.

Skills

Communication skills

Empathy

Data analysis

Relationship building

Education

NVQ Level 3 in adult care or equivalent

Healthcare, social care, or gerontology-related qualifications

Tools

MS Office

Web-based services

Job description

South Hambleton and Ryedale Primary Care Network

Care Coordinator - Age Well

The closing date is 05 January 2026

Join SHaR PCN as a Care Co‑ordinator in our innovative "Age Well" team, supporting older people across Ryedale and South Hambleton. This exciting role focuses on prevention and early intervention to improve the health and wellbeing of people over 65. You’ll be working proactively to identify and support older people, particularly those who are frail or living with long‑term conditions including cancer, helping them navigate health and care services whilst addressing wider determinants like poor housing, loneliness and caring responsibilities. Working within our award‑winning Primary Care Network of seven GP practices, you’ll be the key contact for older people and their families, building trusted relationships and coordinating personalised care plans based on what matters most to them. You’ll collaborate with GPs, nursing staff, Occupational Therapists, social prescribers and voluntary sector partners as part of an integrated neighbourhood team. This is an opportunity to make a genuine difference in people’s lives, enabling older people to maintain independence and live well in their communities while developing your career in a supportive, forward‑thinking environment. If you’re passionate about holistic care coordination and want to help older people thrive, we’d love to hear from you.

Main duties of the job

• Act as first point of contact for older people entering the Age Well pathway, building trusted therapeutic relationships
• Proactively identify and engage older people based on robust data analysis, particularly those who are frail or have long‑term conditions including cancer
• Conduct comprehensive assessments to identify care and support needs for older people and their families/carers
• Develop and coordinate personalised care and support plans (PCSP) based on what matters most to each person
• Provide ongoing case management through regular check‑ins, supporting people to maintain or regain independence
• Coordinate care across multiple agencies including GPs, nursing staff, Occupational Therapists, social care and voluntary sector
• Navigate older people and their families through health and care services, ensuring timely access to appropriate support
• Support people to access enablement approaches, living skills, adaptations and simple safeguards to maintain independence
• Maintain accurate, appropriately coded clinical records and communicate care plans to relevant professionals
• Work as part of an integrated neighbourhood team, acting as a conduit between patients, families and health professionals

About us

SHaRPCN is an award‑winning Primary Care Network serving seven GP practices across Ryedale and South Hambleton. We’re committed to delivering innovative, person‑centred care that addresses both medical needs and wider determinants of health. Our well‑established Personalised Care Team includes Occupational Therapists, Health and Wellbeing Coaches, Social Prescribing Link Workers and Care Coordinators, working collaboratively to transform how we support our communities. We’ve recently developed two exciting work streams: "Age Well" for over 65s and "Live Well" for children, young people and families under 65. Our "Age Well" service focuses on prevention and early intervention, enabling older people to live independently and maintain their wellbeing. Our culture values professional development, innovation and collaborative working. We offer excellent training opportunities, supportive clinical supervision and the chance to shape cutting‑edge healthcare delivery. Join a team that’s genuinely making a difference while enjoying a supportive environment that invests in your growth and wellbeing. This is an exciting time to join us as we progress and develop our pioneering "Age Well" service.

Job responsibilities

About the Role

This Care Co‑ordinator position within our "Age Well" service represents an exciting opportunity to join SHaR PCN’s innovative approach to supporting older people. You’ll be working at the forefront of preventative healthcare, helping older people achieve better health outcomes through early intervention and coordinated care that addresses what truly matters to them.

As part of our award‑winning Primary Care Network spanning seven GP practices, you’ll be embedded within our established Personalised Care Team. This role specifically focuses on our "Age Well" work stream, which addresses the health and wellbeing needs of people over 65, working proactively with robust data analysis to optimise health outcomes through early intervention and holistic support.

The Age Well Approach

The "Age Well" service focuses on prevention and early intervention to improve the health and wellbeing of older people. Your role will support the ongoing identification, engagement and case management of older people based on data‑driven approaches and holistic health and care support. You’ll ensure older people can access services and receive appropriate support when they need it, helping them maintain independence and quality of life in their own communities.

Key Responsibilities

Proactive Identification and Engagement

Using population health intelligence and robust data analysis, you’ll proactively identify older people who could benefit from care coordination support. This includes people who are frail, living with long‑term health conditions including cancer, or at risk of health decline. You’ll take referrals from health professionals and work to engage people early, before crises occur.

First Contact and Relationship Building

You’ll serve as the first point of contact for older people entering our Age Well pathway. This involves establishing trusted, supportive relationships with each person and their family or carers. Your empathetic approach and excellent communication skills will be essential in creating an environment where older people feel comfortable discussing their needs, concerns and what matters most to them about maintaining their independence and wellbeing.

Holistic Assessment

You’ll conduct comprehensive, holistic assessments that go beyond medical needs to understand the person’s full situation. This involves exploring wider determinants of health such as housing conditions, financial concerns, social isolation, caring responsibilities and how these impact on their health and wellbeing. You’ll work with the person, their families and carers to understand their priorities and aspirations.

Personalised Care and Support Planning

A central aspect of your role involves developing personalised care and support plans (PCSP) in line with best practice guidelines. You’ll holistically bring together all identified care and support needs, exploring options to meet these within a single, coordinated plan. These plans will be based on what matters most to the person, focusing on maintaining independence, preventing deterioration and supporting people to live well. Plans will be regularly reviewed and updated to reflect changing needs and progress.

Supporting Independence

You’ll work with individuals to help them maintain or regain independence through various approaches including living skills support, signposting to adaptations and equipment, enablement approaches and simple safeguards. Your strength‑based approach will focus on what people can do for themselves whilst ensuring appropriate support is in place where needed.

Care Coordination Across Sectors

You’ll work closely with multiple professionals across different sectors to coordinate support for older people and their families. This includes liaising with GPs, nursing staff, Occupational Therapists within the Personalised Care Team, social prescribing link workers, social care, voluntary sector organisations and other PCN colleagues. Your role as a conduit will ensure older people receive seamless, well‑coordinated care that addresses their complex needs.

Ongoing Case Management

You’ll maintain ongoing relationships with older people through regular check‑ins and follow‑ups, helping them make progress towards their planned outcomes. This involves monitoring their wellbeing, identifying any deterioration or new concerns early, adapting care plans as needed, and ensuring people feel supported throughout their journey. You’ll track whether people are receiving the support outlined in their plans and take action if there are delays or barriers.

Navigation and Information Provision

Your role includes helping older people and their families navigate the often complex health and care system. You’ll answer queries, make and manage appointments, and ensure people have good quality written or verbal information to help them make informed choices about their care. You’ll develop in‑depth knowledge of local health and care infrastructure, community resources and voluntary sector services to enable effective signposting and referrals.

Working with Frailty and Long‑Term Conditions

A significant focus of your work will be supporting people who are frail or living with long‑term health conditions including cancer. You’ll need to understand the complexities involved medically, physically, emotionally and socially and work sensitively with people at vulnerable times in their lives. You’ll collaborate with clinical colleagues to ensure care plans address both clinical and non‑clinical needs.

Professional Collaboration

Working within our integrated neighbourhood team, you’ll collaborate with diverse health and care professionals. This includes attending multidisciplinary team meetings, preparing reports for clinical leads, and ensuring effective information sharing whilst maintaining appropriate confidentiality. You’ll work particularly closely with the Personalised Care Team Occupational Therapist who provides your line management and clinical supervision.

Service Development and Quality Improvement

As part of implementing and developing the Age Well model of care, you’ll provide valuable feedback on service delivery, help identify improvements and bottlenecks through process mapping, and contribute to developing effective communication channels between all stakeholders. Your insights about what works well for older people will be crucial in refining our approach.

Health Inequalities and Engagement

You’ll play a vital role in identifying health inequalities within our older population and providing feedback on how engagement could be enhanced. This is particularly important for reaching older people who may be isolated or whom statutory services find hard to reach. You’ll work proactively to ensure equitable access to services for older people from all backgrounds and communities.

Record Keeping and Information Governance

You’ll maintain accurate, appropriately coded records in patients’ notes, including details of services they are referred to and outcomes of interventions. You’ll ensure personalised care and support plans are communicated to GPs and other professionals involved in each person’s care and uploaded to relevant online care records. All work will be conducted in accordance with information governance policies, maintaining confidentiality whilst ensuring appropriate information sharing to support coordinated care.

You’ll be based across Ryedale and South Hambleton, working within a supportive team environment that values innovation, collaboration and professional development. The role requires the ability to visit people in their own homes where appropriate, within organisational policies and lone‑working procedures.

Our PCN is committed to creating an inclusive workplace that supports staff wellbeing and professional growth. You’ll have access to comprehensive training opportunities, including programmes aligned with the Personalised Care Institute’s core curriculum, clinical supervision from the Personalised Care Team Occupational Therapist, and support from our PCN Clinical Lead.

Career Development and Learning

This position offers significant opportunities for professional development within the expanding field of personalised care coordination for older people. You’ll be supported to undertake continual personal and professional development, with clear expectations around maintaining evidence of learning activities and participating in annual performance reviews.

The role provides exposure to cutting‑edge healthcare delivery models focused on frailty, ageing well and preventative care. You’ll be working at the forefront of healthcare transformation, helping to shape how we support older people in our community whilst advancing your own career in this exciting and rapidly evolving field.

Person Specification

Qualifications

• NVQ Level 3 in adult care (advanced level) or equivalent qualifications, or demonstrable commitment to working towards these
• Demonstrable commitment to professional and personal development, enrolled in, undertaking or qualified from appropriate training as set out in the Personalised Care Institute core curriculum
• Proficiency in MS Office and web‑based services
• Healthcare, social care or gerontology‑related qualifications
• Training in motivational interviewing, coaching techniques or behaviour change approaches
• Completed safeguarding training relevant to vulnerable adults
• Training or qualification related to frailty, long‑term conditions or end‑of‑life care

Experience

• Experience of working in health, social care and other support roles in direct contact with people, families or carers (in paid or voluntary capacity)
• Experience of supporting people, their families and carers in a related role
• Experience of working with vulnerable people, complying with best practice and relevant legislation
• Experience of working directly in a care co‑ordinator role, adult health and social care, or with older people
• Experience of working with older people who are frail or have long‑term conditions
• Experience of working within multi‑professional team environments
• Experience or training in personalised care and support planning
• Experience of data collection and using tools to measure service impact
• Experience of supporting people to maintain independence through enablement approaches

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 name

South Hambleton and Ryedale Primary Care Network