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Pcn patient care coordinator ageing well service

Lincoln
NHS
Patient care coordinator
Posted: 2 March
Offer description

Job Summary

Are you passionate about making a real difference to older people and those living in care homes? Do you thrive on bringing people together and ensuring patients receive the right support at the right time?

IMP Healthcare is recruiting a Care Coordinator to join our Ageing Well team, supporting the Enhanced Health in Care Homes (EHCH) and housebound services. Working alongside GPs, ANPs and the wider multidisciplinary team, you will proactively manage a caseload of patients with complex or changing needs, coordinate care across primary, community and secondary services, and promote shared decision‑making.


About Us

IMP Healthcare is a Primary Care Network (PCN) comprising nine GP practices that deliver high‑quality, integrated healthcare to approximately 74,000 patients in North Lincolnshire and surrounding areas. We focus on EHCH, frailty, long‑term condition management, and improving access to primary care services, with a commitment to reducing health inequalities and supporting patients to remain well and independent within their communities.


Job Details

* Date posted: 19 February 2026
* Salary: Depending on experience
* Contract: Permanent
* Working pattern: Full‑time
* Reference number: B0324-26-0002
* Job location: Chamber of Commerce, Commerce House, Lincoln, LN2 2WJ


Job Description


Clinical Coordination & Caseload Management

* Proactively identify and manage a defined caseload of patients within the Ageing Well cohort.
* Coordinate and organise staff rotas on SystmOne for ANP, Frailty Nurse, Occupational Therapist and Pharmacist clinics.
* Contact patients via their preferred communication method to invite them into the service and arrange appointments.
* Support seamless transitions between primary, community and secondary care.
* Liaise regularly with GPs, ANPs, pharmacists, social prescribers and community teams to ensure coordinated care delivery.
* Actively participate in multidisciplinary team (MDT) meetings and support preparation and follow‑up actions.


Personalised Care & Support Planning

* Conduct home visits for housebound patients where appropriate.
* Review and update care plans at agreed intervals.
* Promote shared decision‑making conversations.
* Ensure care plans are communicated to relevant professionals and recorded accurately in clinical systems.
* Escalate any clinical concerns to supervising clinician.


Navigation & Signposting

* Develop an in‑depth understanding of local health, community and voluntary sector services.
* Support appropriate onward referrals to social prescribing link workers and other services.
* Help patients navigate the wider health and care system.
* Identify when additional support or intervention is required and raise concerns promptly.


Digital & Data Responsibilities

* Maintain accurate, contemporaneous documentation within SystmOne.
* Record activity using appropriate SNOMED/read codes to support reporting and audit.
* Support data quality improvement within the Ageing Well service.
* Use digital systems to track patient progress and outcomes.
* Contribute to monitoring service activity and performance metrics.


Governance, Safety & Compliance

* Adhere to safeguarding policies Adults & Children and elevate concerns appropriately.
* Follow lone working procedures during home visits.
* Maintain patient confidentiality and comply with information governance standards.
* Identify and report risks or incidents in line with PCN policy.
* Participate in clinical supervision sessions with supervising GP/ANP.
* Work within the defined scope of the Care Coordinator role and avoid providing clinical advice beyond competence.


Service Improvement & Development

* Identify service gaps and provide feedback to improve delivery.
* Contribute to quality improvement initiatives within the PCN.
* Support service monitoring through accurate recording of interventions and outcomes.
* Assist in evaluation of patient experience within the service.


Professional Development

* Participate in regular one‑to‑one supervision meetings.
* Engage in mandatory training and ongoing professional development.
* Take part in annual appraisal and objective setting.
* Work collaboratively with other Care Coordinators across the PCN.


Outcome Expectations

* Increased completion of personalised care plans.
* Improved frailty identification and coding accuracy.
* Reduction in avoidable hospital admissions where appropriate.
* Improved patient experience and continuity of care.
* Effective MDT coordination and follow‑up.


Wider Responsibilities

* Support the delivery of QOF, incentive schemes, QIPP and other quality or cost‑effectiveness initiatives.
* Undertake any tasks consistent with the level of the post and the scope of the role, ensuring work is delivered in a timely and effective manner.
* Duties may vary from time to time without changing the general character of the post or the level of responsibility.


Person Specification


Experience

* Essential – Experience of working in a healthcare setting or a public‑facing role, excellent customer service skills.
* Desirable – Primary Care/General Practice experience; Excellent IT and computer skills including SystmOne experience.


Qualifications

* Essential – Good standard of secondary education, including Maths and English.
* Desirable – Healthcare related qualification.


Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and requires a Disclosure and Barring Service check to ensure no previous criminal convictions.


Certificate of Sponsorship

Applications from job seekers who require current Skilled Worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website.


Employer Details

IMP Federation Ltd
Chamber of Commerce, Commerce House, Lincoln, LN2 2WJ
Website: http://imphealthcare.co.uk/

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