Care Coordinator - Live Well Team

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

Job summary

A local primary care provider in Easingwold is seeking a Care Coordinator to join their Live Well team. The role focuses on supporting families through preventative healthcare, facilitating access to services, and tailoring care plans to individual needs. Ideal candidates will have strong communication skills and experience in family support. This position offers a chance to impact community health positively while fostering your professional development in a nurturing environment.

Benefits

Comprehensive training opportunities

Supportive team environment

Professional development programs

Qualifications

• Experience in health or social care directly with families or individuals.
• Proven proficiency in communication and relationship management.
• Demonstrable commitment to ongoing personal and professional development.

Responsibilities

• Act as the first point of contact for families.
• Develop and coordinate personalized care and support plans.
• Navigate and connect families to local health and care services.

Skills

Relationship building

Assessment skills

Communication

Case management

Motivational interviewing

Education

NVQ Level 3 in adult care or equivalent

Training in motivational interviewing

Tools

MS Office

Web-based services

Job description

Go back South Hambleton and Ryedale Primary Care Network

Care Coordinator - Live Well Team

The closing date is 05 October 2025

Join SHaR PCN as a Care Co-ordinator in our innovative 'Live Well' team, supporting children, young people and families across Ryedale and South Hambleton. This exciting role focuses on prevention and early intervention, helping families navigate health and care services whilst addressing wider determinants like housing, debt and loneliness. You\'ll be the first point of contact for families, building trusted relationships and coordinating personalised care plans that truly make a difference. Working within our award-winning Primary Care Network of seven GP practices, you\'ll collaborate with GPs, health visitors, social prescribers and voluntary sector partners. This is an opportunity to shape the future of family-centred care, supporting some of our most vulnerable community members whilst developing your career in a supportive, forward-thinking environment. If you\'re passionate about holistic care co-ordination and want to help families thrive, we\'d love to hear from you.

Main duties of the job

• Act as first point of contact for families entering the Live Well pathway, building trusted therapeutic relationships
• Identify selected patients via defined processes and conduct comprehensive assessments of care and support needs
• Develop and coordinate personalised care and support plans (PCSP) based on what matters most to each family
• Provide ongoing case management through regular check-ins and progress monitoring towards planned outcomes
• Coordinate care across multiple agencies including GPs, school nursing, health visitors, children\'s social care and voluntary sector
• Navigate families through health and care services, ensuring timely access to appropriate support and resources
• Maintain accurate, appropriately coded clinical records and communicate care plans to relevant professionals
• Identify health inequalities and provide feedback on engagement strategies to enhance service delivery
• Support implementation of this new model of care and contribute to service development and improvement
• Work closely with the Safeguarding Care Co-ordinator and Social Prescribing Link Worker for younger people and families
• Travel flexibly across all seven SHaR PCN practices (Pickering, Kirkbymoorside, Helmsley, Terrington, Stillington, Tollerton, and Millfield) while based from Easingwold Health Centre. Deliver community-based support and maintain strong working relationships with practice teams across the network.

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 Co-ordinators, 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 culture values professional development, innovation and collaborative working. We offer excellent training opportunities, supportive supervision and the chance to shape cutting-edge healthcare delivery. Join a team that\'s genuinely making a difference whilst 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 \'Live Well\' service.

Job responsibilities

About the Role

This Care Co-ordinator position within our \'Live Well\' service represents an exciting opportunity to join SHaR PCN\'s innovative approach to supporting children, young people and families. You\'ll be working at the forefront of preventative healthcare, helping families 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 \'Live Well\' work stream, which addresses the health and wellbeing needs of children, young people and families under 65, working proactively to optimise health outcomes through early intervention.

Key Responsibilities

First Contact and Relationship Building You\'ll serve as the first point of contact for families entering our Live Well pathway. This involves quickly establishing trusted, supportive relationships with each family or young person we work with. Your empathetic approach and excellent communication skills will be essential in creating an environment where families feel comfortable discussing their needs, concerns and aspirations for better health and wellbeing.

Assessment and Identification Following defined identification processes, you\'ll contact patients and families to conduct further triage and comprehensive assessments. This involves exploring their holistic care and support needs, identifying areas requiring intervention, and understanding what matters most to them. Your assessment skills will be crucial in ensuring families receive appropriate, timely support.

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 based on what matters to each person and family. These plans will be regularly reviewed and updated to reflect changing needs and progress towards outcomes.

Care Co-ordination Across Sectors You\'ll work closely with multiple professionals across different sectors to co-ordinate support for patients and their families. This includes liaising with GPs, school nursing, health visitors, social prescribing link workers, children\'s social care, voluntary sector organisations and other PCN colleagues. Your role as a conduit will ensure families receive seamless, well-coordinated care that addresses their complex needs.

Ongoing Case Management You\'ll maintain ongoing relationships with families through regular check-ins, helping them make progress towards their planned outcomes and supporting them to access the right resources and services. This involves monitoring progress, identifying barriers, adapting plans as needed, and ensuring families feel supported throughout their journey.

Navigation and Information Provision Your role includes helping families navigate the often complex health and care system, answering queries, making and managing appointments, and ensuring 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 to enable effective signposting and referrals.

Professional Collaboration and Communication Working within our integrated neighbourhood team, you\'ll collaborate with diverse health and care professionals, ensuring effective communication and information sharing. This includes preparing reports for clinical leads, participating in multidisciplinary team meetings, and ensuring care plans are communicated to GPs and other professionals involved in each person\'s care.

Service Development and Quality Improvement As part of implementing this new 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 will be crucial in adapting and improving the service to best meet patient needs.

Health Inequalities and Engagement You\'ll play a vital role in identifying health inequalities within our patient population and providing feedback on how engagement could be enhanced. This aligns with our commitment to reducing health disparities and ensuring equitable access to services for all families in our diverse communities.

Record Keeping and Information Governance You\'ll maintain accurate, appropriately coded records in patients\' notes, including details of services they are referred to. 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 offers flexibility whilst ensuring you have access to clinical supervision from the Senior Social Prescribing Link Worker for Live Well and support from our PCN Clinical Lead.

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, and support for your ongoing professional development.

Career Development and Learning

This position offers significant opportunities for professional development within the expanding field of personalised care co-ordination. 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 and the opportunity to contribute to the development of this innovative service. You\'ll be working at the forefront of healthcare transformation, helping to shape how we support families in our community whilst advancing your own career in this exciting and rapidly evolving field.

Location & Travel Requirements

While based at Easingwold Health Centre, you\'ll be required to travel flexibly across all seven of our GP practices (Pickering, Kirkbymoorside, Helmsley, Terrington, Stillington, Tollerton, and Millfield) to deliver services and support patients in their local communities. This role therefore requires a current full driving licence and sole use of your own vehicle.

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
• Additional healthcare, social care or related qualifications
• Training in motivational interviewing, coaching techniques or behaviour change approaches
• Completed safeguarding training relevant to children and vulnerable adults

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
• Proficiency in MS Office and web-based services
• Experience of working directly in a care co-ordinator role, adult health and social care, learning support or public health/health improvement
• 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 the impact of services

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