Proactive Anticipatory Care (PAC) Neighborhood Care Coordinator

Sutton Primary Care Networks; Sutton Coldfield; On-site; GBP 24,000 - 30,000; Full time

Job summary

A regional healthcare provider in Sutton Coldfield is seeking a Proactive Anticipatory Care Neighborhood Care Coordinator. This role involves coordinating personalized, proactive care for patients and facilitating communication across health and social services. Ideal candidates will have experience in health or social care, GCSE qualifications, and strong collaboration skills. This position offers an opportunity to make a meaningful impact in the local healthcare community.

Qualifications

• Educated to GCSE level.
• Experience in health or social care sector.
• Professional development and maintaining knowledge.

Responsibilities

• Coordinate care for patients in a multidisciplinary team.
• Produce quality notes after MDT meetings.
• Participate in evaluations of patient goals and outcomes.

Skills

Communication

Collaboration

Patient Care Coordination

Motivational Interviewing

Assessment Skills

Education

GCSE level with English and Mathematics at grade C or above

NVQ level 3 in related field

Job description

Proactive Anticipatory Care (PAC) Neighborhood Care Coordinator

The ProactiveAnticipatory Care Neighbourhood Care Coordinator will support the delivery ofpersonalised, proactive, and holistic care within the Primary Care Network.Working as part of a multidisciplinary team, the postholder will coordinatecare for a defined caseload of patients, ensuring timely communication,collaboration, and follow-up across health, social care, and communityservices. Acting as a central point of contact for patients, families, andprofessionals, the Coordinator will facilitate effective anticipatory careplanning, monitor outcomes, and promote continuity of care to improve healthand wellbeing within the neighbourhood population.

Main duties of the job

To support the delivery ofpersonalised, proactive, and holistic care within the Primary Care Network(PCN), working as part of a multidisciplinary team (MDT).

To be responsible for acaseload of patients aligned to aspecific neighbourhood primary care team.

Ensure the rightprofessionals are involved, notified and prepared for the meetings inadvance.

Produce high quality notesfollowing MDT meetings to include agreed and assigned actions.

Carry out home visits forassessment, monitoring, and delivery of care as appropriate.

Participate in the reviewof patient outcomes and goals over time.

Act as a central,continuous point of contact for the patient, their relatives/carers andthe professionals involved in the care plan.

Collaborate with communityteams, families, carers, and external partners to support coordinated caredelivery.

Effectively signpostpatients to appropriate health and wellbeing services that are best placedto meet unmet care needs.

Work collaboratively withthe nursing team and social prescribing team within the PAC service andescalate patients who require more specialised input from those serviceswhen required.

Support the coordinationand implementation of personalised care plans reflecting patientpreferences, goals, and needs.

Refer or request referralson patients behalf to appropriate services that can assist with meetingoutstanding care needs.

About us

Sutton PCNs is the network of Sutton PCNs working together in Sutton and is also the local GP Federation. All GP practices in Sutton are shareholders (members) of the Sutton PCNs and our Board provides clear leadership through strong GP practice/PCN representation. Our mission is to work collaboratively with patients, practices, the emerging Primary Care Networks (PCNs) and staff to deliver consistently outstanding health and care services for all our communities.

As is the case elsewhere, Primary Care in Sutton is under extreme pressure. The challenge for Sutton PCNs is to work in partnership with our local ICB our four PCNs (and 24 practices) and the wider Integrated Care System in Southwest London to help shape and implement the transformation of Primary Care in Sutton to ensure that it can both survive and thrive while shifting to population health approaches to health and care.

The Sutton PCNs shape and deliver health care with our practices to improve patient outcomes. We have developed a comprehensive strategy for the development of the Sutton PCNs. The post holder will have a key role in supporting the development of our Extended Access and as such will be required to have significant experience of either primary care or development of small or emerging organisations. You'll be joining a great team in a great place, where your commitment will be genuinely valued, your skills respected, and your ambition rewarded.

Job responsibilities

• Participate in weekly referral triage meetings to assist in identifying appropriate referrals.
• Work closely with the PAC MDT coordinators to ensure that GP/complex meetings are arranged, coordinated, and communicated, with all necessary information available in a timely manner.
• Ensure all records are comprehensive, complete, available. Update patients records and universal care plan in timely manner to ensure coordinators and other service providers have access to any patient updates/progress.
• Present yourself as an ambassador for the service and attend external practice/service meetings to promote the PAC MDT service when necessary.
• Attend relevant PAC service meetings as required.
• Ensure that all PAC service policies are fully adhered to.
• Participate in evaluating patient goals and outcomes to help guide ongoing care plans and support improvements within the service.
• Direct patients to suitable services and resources to support their empowerment and enable them to manage their own health.
• Must have a full, clean driving licence and access to a car for home visits

Person Specification

Qualifications

• -Educated to GCSE level, including English and Mathematics at grade C or above or equivalent.
• - Previous experience of working in health or social care sector.
• -Evidence of appropriate continuing professional development and education to maintain up to date knowledge.
• -Previous experience working as a HCSW.
• -Training in coaching, motivational interviewing, or care navigation
• - NVQ level 3 in related field.

Experience

• -Significant previous experience in project or team administration.
• -Previous experience working within a busy team or project office.
• -Supporting implementation of projects or new initiatives
• -Supporting the monitoring of information and evaluation of a new project or initiative.
• -Previous work within the NHS, social care or voluntary and community sector.
• -Previous work within multi-disciplinary teams.

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.

Depending on experienceAligned with NHS Band 4