PCN Care Coodinator

Allscreens Nationwide Ltd; Swindon; On-site; GBP 32,000 - 52,000; Full time

Job summary

Allscreens Nationwide Ltd in Swindon seeks a dedicated care coordination professional to develop and maintain a directory of local services, support unpaid carers, and coordinate safe hospital discharges across age groups.

You will work with Adult Social Care, social workers, district nurses, therapists, and care homes to ensure timely assessments, appropriate packages, vaccinations, and smooth transitions for patients within the health and care system.

Responsibilities

• Develop and maintain a directory of local services (charities, voluntary and private providers) with up-to-date information.
• Provide support to unpaid carers via carer clinics, offering guidance, signposting, emotional support, and access to services or respite options.
• Coordinate hospital discharge for patients under/over 75, ensuring timely follow-up, medication reviews, and clear communication with families.
• Coordinate referrals to Adult Social Care with social workers for timely assessments and care packages.
• Collaborate with District Nurses, Occupational Therapists and Physiotherapists to support holistic care planning and referrals.
• Escalate safeguarding concerns to Adult Social Care and coordinate care assessments; build relationships with care homes to promote wellbeing, coordinate vaccinations, and social prescribing visits.
• Arrange wheelchair assessments and referrals; assist access to mobility equipment and home adaptations.
• Coordinate Dementia Reviews with clinics, support carers, gather input from GPs and community services, and follow up actions.
• Run NHS Health Check clinics from assessment to results, referrals, and lifestyle interventions, ensuring follow-through for patients.
• Manage LWT responsibilities across the team, ensuring timely completion and proper documentation.
• Streamline care for patients with complex needs to smooth their journey and accelerate access to support.
• Use clinical criteria and population health tools to flag individuals for coordinated care.
• Respond to patient queries with clear information to understand health and care plans.
• Arrange appointments and promote vaccination uptake for eligible groups.
• Tailor support to individuals' priorities, culture, values, disabilities and long-term conditions.
• Coordinate transitions between health system parts to ensure timely referrals and no gaps.
• Maintain a defined caseload and act as a consistent contact across care settings.
• Oversee referrals to clinical and non-clinical services and maintain communication with teams and partner organisations.
• Provide calm, practical support to those overwhelmed navigating the care system to reduce distress.
• Address health inequalities by focusing on priority groups with multiple health needs.

Job description

Primary Responsibilities

• Develop and maintain a comprehensive directory of local services, including charities, community and voluntary sector organisations, and relevant private providers, ensuring up-to-date information is available for staff and service users.
• Deliver dedicated support to unpaid carers through carer clinics, offering guidance, signposting, emotional support, and assistance in accessing appropriate services or respite options.
• Coordinate safe and effective hospital discharge processes for patients under and over 75, ensuring timely follow-up care, medication reviews, and clear communication with families and community services.
• Manage referrals to Adult Social Care, liaising closely with social workers to ensure individuals receive timely assessments and appropriate care packages that meet their needs.
• Work collaboratively with community health teams, including District Nurses, Occupational Therapists, and Physiotherapists, to support holistic care planning and facilitate referrals for clinical or functional support.
• Engage Adult Social Care when issues of safeguarding or the need for a care assessment arise, ensuring concerns are escalated appropriately Build strong working relationships with care homes and teams supporting housebound patients to promote resident wellbeing, coordinate vaccinations, arrange social prescribing visits, and ensure effective communication between all involved providers.
• Arrange wheelchair assessments and referrals and support individuals in accessing appropriate mobility equipment and adaptations.
• Conduct and coordinate Dementia Reviews, including running assessment clinics, supporting carers, gathering input from GPs and community services, and ensuring follow-up actions are completed.
• Deliver NHS Health Check clinics, overseeing the full process from assessment to coordination of results, referrals, and lifestyle interventions to ensure effective follow-through for patients.
• Manage, monitor, and allocate LWT responsibilities across the team, ensuring timely completion, consistent documentation, and effective workflow coordination.

Secondary Responsibilities

• Work alongside practice teams to streamline care for patients with complex or long-term needs, aiming to smooth their journey through the system and accelerate access to appropriate support.
• Use agreed clinical criteria and population health management tools to flag individuals who would benefit from coordinated care, ensuring proactive rather than reactive support.
• Respond to patient queries and provide clear, accessible information that helps them understand and manage their health and care plans.
• Arrange patient appointments as needed and promote vaccination uptake among eligible groups to support prevention and early intervention.
• Tailor support to each person's priorities, ensuring care is sensitive to cultural background, personal values, disabilities and long-term conditions.
• Coordinate transitions between different parts of the health and care system, ensuring referrals are timely and that patients move smoothly between services without gaps in support.
• Hold a defined caseload and act as a consistent point of contact for patients across primary care, community services, secondary care and care home environments.
• Oversee referrals to clinical and non-clinical services, maintaining effective communication with internal healthcare teams and wider partner organisations.
• Provide calm, practical support to people who feel overwhelmed or uncertain about navigating the care system, helping them build confidence and reduce distress.
• Address health inequalities through focused work with priority groups, including people with multiple health needs or those at higher risk of poor outcomes.