PCN Care Coordinator

The Methodist Church in Britain; Bradley Stoke; On-site; GBP 28,000 - 38,000; Full time

Job summary

The North & South Gloucestershire Primary Care Network is seeking a Care Coordinator to join the Living Well Team. The role focuses on joining up health, social care and community support for people with complex needs, including older or frail patients.

Based at The Alney Practice, duties include home visits, MDT meetings and helping patients navigate services. Applicants should be able to build trusting relationships, plan personalised care, and work across multiple services with care

Qualifications

• Five GCSEs or equivalent.
• Commitment to continuing professional development, including Personalised Care Institute courses.

Responsibilities

• Coordinate care across GP practices and services.
• Lead MDT meetings including agendas and minutes.
• Develop personalised care and support plans.
• Attend MDT meetings and follow actions.
• Assist patients to navigate services with coaching.
• Support patients around clinical appointments.
• Identify patients needing anticipatory coordinated support.
• Work with Living Well Team to keep patients well.
• Develop data collection systems to monitor and evaluate services.

Skills

Communication

Active listening

Rapport building

Organisation

Prioritisation

Independent worker

MDT teamwork

IT systems

Education

Five GCSEs or equivalent

Personalised Care Institute course(s)

Tools

EMIS

SystmOne

MS Office

Job description

This Care Coordinator post sits in the Living Well Team of North & South Gloucestershire Primary Care Network, alongside frailty nurses and social prescribing link workers. The work centres on joining up health, social care and community support for people with complex needs, particularly older or frail patients and those with long-term conditions. Based mainly at The Alney Practice, it includes home visits and running the network's multidisciplinary team meetings. Applicants need their own transport, and visa sponsorship is not available.

What the job involves

• Coordinate care across GP practices, community services and social care, acting as a point of contact for patients, families and professionals
• Build trusting, person-centred relationships with patients and carers, including home visits for those with complex needs
• Bring together identified needs into a single personalised care and support plan that reflects individual goals
• Lead the organisation, coordination and delivery of PCN multidisciplinary team meetings, including agendas and minutes
• Attend MDT meetings, record actions and follow them up within agreed timescales
• Help patients navigate health, social care and community services and understand their options, using a coaching approach
• Support patients before and after clinical appointments, helping them prepare and understand next steps
• Identify patients who need anticipatory coordinated support, using local knowledge and population health intelligence
• Work with the Living Well Team to help people stay well and independent
• Develop data collection systems to monitor and evaluate services, using information responsibly
• Raise awareness of shared decision making and decision support tools across the PCN

What’s required

Qualifications

• Good standard of education, five GCSEs or equivalent
• Commitment to continuing professional development, including Personalised Care Institute course(s)

Experience

• Experience in a patient-facing, client-facing or support role in healthcare, social care, voluntary or community settings
• Understanding of patient-centred care and of supporting people with complex needs, including long-term conditions or frailty
• Experience of working with multiple services or professionals to support individuals

Skills & knowledge

• Excellent communication, listening and rapport-building with patients, carers and professionals
• Strong organisation and prioritisation across a varied workload
• Ability to work independently and as part of a multidisciplinary team
• Confident using IT systems, including MS Office, patient records and digital tools, and willing to learn new systems

Checks & eligibility

• Eligible to work in the UK, as no visa sponsorship is available
• Own transport for home visits and travel between PCN sites

Other

• Compassionate, empathetic and person-centred approach
• Commitment to dignity, inclusion, equality and high-quality patient care
• Calm, professional and resilient when working with people with complex needs
• Willingness to undertake further training, including progression to Advanced Care Coordinator

Nice to have

• Further education qualifications
• Training in health coaching, motivational interviewing or equivalent
• Willingness to learn, develop and adapt within a developing PCN role
• Experience within the NHS, primary care, social care or a similar health or community setting
• Experience supporting older people, frail patients or those with long-term conditions
• Experience of MDT working and contributing to care planning or reviews
• Experience of care coordination, navigating services, following up actions and acting as a point of contact
• Experience using clinical systems, preferably EMIS and/or SystmOne

What’s offered

• Career progression to Advanced Care Coordinator after a qualifying period, with salary uplift