LTC Proactive Care Coordinator

NHS Jobs; Romford; Presencial; GBP 32.000 - 42.000; Jornada completa

Descripción de la vacante

The NHS Jobs is seeking an LTC Proactive Care Coordinator to support delivery of LTC LIS and QOF outcomes. You will coordinate proactive care activities for patient cohorts, facilitate MDT meetings, and maintain accurate clinical records using EMIS.

You will identify eligible patients for annual reviews, manage call and recall processes, and help ensure timely reviews, personalised care planning and integrated support across community, social care and secondary care partners.

Formación

• Experience coordinating MDT meetings and care planning.
• Ability to identify eligible patients and manage call/recall processes.
• Experience with EMIS and clinical record-keeping.

Responsabilidades

• Organise regular LTC MDT meetings at practice, PCN or neighbourhood level.
• Prepare patient lists and case summaries for discussion.
• Record actions and care plans from MDT meetings.
• Run EMIS searches and support performance monitoring.
• Support delivery of Year of Care and social prescribing.

Conocimientos

Coordination

Communication

Teamwork

Herramientas

EMIS

Descripción del empleo

The LTC Proactive Care Coordinator will support delivery of the NEL Long Term Conditions (LTC) Proactive Care Quality and Outcomes Framework. The post holder will coordinate proactive care activities for identified patient cohorts, facilitate multidisciplinary team (MDT) meetings, undertake call and recall processes, maintain accurate clinical records using EMIS, and support achievement of the LTC Local Incentive Scheme (LIS) requirements and outcomes. The role will ensure patients receive timely reviews, personalised care planning and coordinated support, contributing to improved health outcomes, reduced health inequalities and enhanced patient experience.

Key Duties and Responsibilities include:

MDT Coordination

• Organise and coordinate regular LTC MDT meetings at practice, PCN or neighbourhood level.
• Prepare patient lists and case summaries for discussion.
• Record actions, outcomes and agreed care plans from MDT meetings.
• Track completion of MDT actions and follow up with relevant clinicians and services.
• Liaise with community, mental health, social care, voluntary sector and secondary care partners as required.
• Ensure MDT discussions support personalised and holistic care planning.

Call and Recall Processes

• Identify eligible patients for LTC reviews using approved searches and cohort criteria.
• Operate systematic call and recall processes for annual reviews, care planning appointments and follow-up interventions.
• Contact patients via telephone, SMS, letters and other approved communication channels.
• Monitor uptake and non-attendance and take appropriate follow-up action.
• Maintain accurate records of invitations, appointments and outcomes.

EMIS Administration and Data Quality

• Maintain and update patient records using EMIS.
• Apply agreed LTC templates and care planning tools.
• Ensure appropriate clinical coding and recording of care plan activity, wider determinants of health, personalised care discussions and MDT outcomes.
• Support data quality improvement by identifying coding gaps and outstanding actions.
• Run EMIS searches and reports to support performance monitoring and service delivery.
• Ensure information is recorded in accordance with PCN, ICB and information governance requirements

Care Planning Support

• Support delivery of the Year of Care approach.
• Assist patients to access appropriate services, including social prescribing, community services and self-management support.
• Ensure care plans reflect patient goals, preferences and identified needs.
• Support identification and recording of wider determinants of health.

Performance and Reporting

• Monitor progress against LTC LIS targets and outcomes.
• Produce reports on call and recall activity, review completion rates and MDT outcomes.
• Escalate risks relating to performance, patient engagement or service delivery.
• Support practices and PCN teams to achieve contractual and quality requirements.

Key Collaborative Working Relationships

• PCN Leadership and Management Team
• GPs,
• Practice Managers,
• nurses and other practice staff
• Clinical Pharmacists
• Social Prescribers
• Community Services
• Mental Health Professionals
• Adult Social Care
• Voluntary Sector
• Secondary Care Partners