Care Coordinator - Live Well Team

South Hambleton and Ryedale Primary Care Network; York and North Yorkshire; On-site; GBP 25,000 - 35,000; Full time

Job summary

A primary care network in North Yorkshire is seeking a Care Coordinator for their Live Well team. This role focuses on providing support for children and families, helping navigate health services and ensuring personalized care plans. The ideal candidate will have strong communication and relationship-building skills, alongside experience in health or social care. You'll work within a collaborative team to promote well-being and improve health outcomes. Join an innovative environment dedicated to making a real difference in the community.

Benefits

Comprehensive training opportunities

Supportive working environment

Qualifications

• Demonstrable commitment to professional and personal development.
• Experience in health, social care, or direct support roles.
• Proficiency in MS Office and web-based services.

Responsibilities

• Act as first point of contact for families entering the Live Well pathway.
• Develop and coordinate personalised care and support plans.
• Provide ongoing case management through regular check-ins.

Skills

Relationship Building

Assessment Skills

Care Coordination

Communication Skills

Knowledge of Health Services

Education

NVQ Level 3 in adult care or equivalent

Training in motivational interviewing

Safeguarding training

Job description

Mynd nôl South Hambleton and Ryedale Primary Care Network

Care Coordinator - Live Well Team

The closing date is 05 Hydref 2025

JoinSHaR PCN as a Care Co-ordinator in our innovative 'Live Well' team, supportingchildren, young people and families across Ryedale and South Hambleton. Thisexciting role focuses on prevention and early intervention, helping familiesnavigate health and care services whilst addressing wider determinants likehousing, debt and loneliness. You'll be the first point of contact forfamilies, building trusted relationships and coordinating personalised careplans that truly make a difference. Working within our award-winning PrimaryCare Network of seven GP practices, you'll collaborate with GPs, healthvisitors, social prescribers and voluntary sector partners. This is anopportunity to shape the future of family-centred care, supporting some of ourmost vulnerable community members whilst developing your career in asupportive, forward-thinking environment. If you're passionate about holisticcare co-ordination and want to help families thrive, we'd love to hear fromyou.

Responsibilities

• 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 acrossRyedale and South Hambleton. We're committed to delivering innovative,person-centred care that addresses both medical needs and wider determinants ofhealth. Our well-established Personalised Care Team includes OccupationalTherapists, Health and Wellbeing Coaches, Social Prescribing Link Workers andCare Co-ordinators, working collaboratively to transform how we support ourcommunities. We've recently developed two exciting work streams: 'Age Well' forover 65s and 'Live Well' for children, young people and families under 65. Ourculture values professional development, innovation and collaborative working.We offer excellent training opportunities, supportive supervision and thechance to shape cutting-edge healthcare delivery. Join a team that's genuinelymaking a difference whilst enjoying a supportive environment that invests inyour growth and wellbeing. This is an exciting time to join us as we progressand 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 innovativeapproach to supporting children, young people and families. You'll be workingat the forefront of preventative healthcare, helping families achieve betterhealth outcomes through early intervention and coordinated care that addresseswhat truly matters to them.

As part of our award-winning Primary Care Network spanningseven GP practices, you'll be embedded within our established Personalised CareTeam. This role specifically focuses on our 'Live Well' work stream, whichaddresses the health and wellbeing needs of children, young people and familiesunder 65, working proactively to optimise health outcomes through earlyintervention.

Key Responsibilities

First Contact and Relationship Building You'll serveas the first point of contact for families entering our Live Well pathway. Thisinvolves quickly establishing trusted, supportive relationships with eachfamily or young person we work with. Your empathetic approach and excellentcommunication skills will be essential in creating an environment wherefamilies feel comfortable discussing their needs, concerns and aspirations forbetter health and wellbeing.

Assessment and Identification Following defined identificationprocesses, you'll contact patients and families to conduct further triage andcomprehensive assessments. This involves exploring their holistic care andsupport needs, identifying areas requiring intervention, and understanding whatmatters most to them. Your assessment skills will be crucial in ensuringfamilies receive appropriate, timely support.

Personalised Care and Support Planning A centralaspect 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 thesewithin a single, coordinated plan based on what matters to each person andfamily. These plans will be regularly reviewed and updated to reflect changingneeds and progress towards outcomes.

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

Ongoing Case Management You'll maintain ongoingrelationships with families through regular check-ins, helping them makeprogress towards their planned outcomes and supporting them to access the rightresources and services. This involves monitoring progress, identifying barriers,adapting plans as needed, and ensuring families feel supported throughout theirjourney.

Navigation and Information Provision Your roleincludes helping families navigate the often complex health and care system,answering queries, making and managing appointments, and ensuring people havegood quality written or verbal information to help them make informed choicesabout their care. You'll develop in-depth knowledge of local health and careinfrastructure to enable effective signposting and referrals.

Professional Collaboration and Communication Workingwithin our integrated neighbourhood team, you'll collaborate with diversehealth and care professionals, ensuring effective communication and informationsharing. This includes preparing reports for clinical leads, participating inmultidisciplinary team meetings, and ensuring care plans are communicated toGPs and other professionals involved in each person's care.

Service Development and Quality Improvement As partof implementing this new model of care, you'll provide valuable feedback onservice delivery, help identify improvements and bottlenecks through processmapping, and contribute to developing effective communication channels betweenall stakeholders. Your insights will be crucial in adapting and improving theservice to best meet patient needs.

Health Inequalities and Engagement You'll play avital role in identifying health inequalities within our patient population andproviding feedback on how engagement could be enhanced. This aligns with ourcommitment to reducing health disparities and ensuring equitable access toservices for all families in our diverse communities.

Record Keeping and Information Governance You'llmaintain accurate, appropriately coded records in patients' notes, includingdetails of services they are referred to. All work will be conducted inaccordance with information governance policies, maintaining confidentialitywhilst ensuring appropriate information sharing to support coordinated care.

You'll be based across Ryedale and South Hambleton, workingwithin a supportive team environment that values innovation, collaboration andprofessional development. The role offers flexibility whilst ensuring you haveaccess to clinical supervision from the Senior Social Prescribing Link Workerfor Live Well and support from our PCN Clinical Lead.

Our PCN is committed to creating an inclusive workplace thatsupports staff wellbeing and professional growth. You'll have access tocomprehensive training opportunities, including programmes aligned with thePersonalised Care Institute's core curriculum, and support for your ongoingprofessional development.

Career Development and Learning

This position offers significant opportunities forprofessional development within the expanding field of personalised careco-ordination. You'll be supported to undertake continual personal andprofessional development, with clear expectations around maintaining evidenceof learning activities and participating in annual performance reviews.

The role provides exposure to cutting-edgehealthcare delivery models and the opportunity to contribute to the developmentof this innovative service. You'll be working at the forefront of healthcaretransformation, helping to shape how we support families in our communitywhilst 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