PCN Patient Care Coordinator Ageing Well Service
Are you passionate about making a real differenceto older people and those living in care homes? Do you thrive on bringingpeople together and ensuring patients receive the right support at the righttime?
IMP Healthcare is recruiting a Care Coordinator tojoin our Ageing Well team, supporting the Enhanced Health in Care Homes (EHCH)and housebound services. Working alongside GPs, ANPs and the widermultidisciplinary team, you will proactively manage a caseload of patients withcomplex or changing needs.
You will join a supportive,collaborative team committed to improving outcomes for vulnerable patientswhile offering structured supervision and opportunities for development.
Main duties of the job
The Care Coordinator will work alongside GPs, ANPs and the wider multidisciplinary team to proactively identify and manage a caseload of patients, particularly those living in care homes or with complex needs. The role involves developing, implementing and regularly reviewing personalised care and support plans, ensuring they are accurately recorded and shared with relevant professionals.
You will coordinate care across primary, community and secondary services, support patients and carers to navigate the health and care system, and promote shared decision-making. The postholder will liaise regularly with care homes, families and partner organisations to ensure a joined-up approach, elevate concerns where required, and participate in MDT meetings.
Accurate documentation, use of clinical systems and contribution to service improvement are key components of the role, alongside maintaining strong working relationships across the PCN.
About us
IMP Healthcare is a Primary Care Network (PCN) comprising nine GP practices working collaboratively to deliver high-quality, integrated healthcare to a population of approximately 74,000 patients across North Lincolnshire and surrounding areas.
The PCN brings together general practice teams and a wide multidisciplinary workforce to provide proactive, patient-centred care closer to home. Key areas of focus include Enhanced Health in Care Homes (EHCH), anticipatory care, frailty, long-term condition management and improving access to primary care services.
IMP Healthcare is committed to reducing health inequalities, improving population health outcomes and supporting patients to remain well and independent within their communities. Through collaborative working, service innovation and strong clinical leadership, the organisation continues to develop responsive services aligned to national priorities and local population need.
Job responsibilities
The Care Coordinator will support the delivery of the Ageing Well service within the Primary CareNetwork, working proactively with patients living with frailty, long-termconditions and complex health and social needs.
ClinicalCoordination & Caseload Management
* Proactively identify and manage a defined caseload of patients within the Ageing Well cohort.
* Coordinate and organise staff rota 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.
PersonalisedCare & Support Planning
Holistically brings together all of a persons identified care and support needs and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person following the NHS Comprehensive Care Model. See also YouTube NHS Comprehensive Personalised Care Model Explainer Animation.
* 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.
Participate in the management of patient complaints when requested to do so and participate in the identification of any necessary learning brought about through incidents and near-miss events.
Maintain a clean, tidy, effective working area at all times
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.
The post-holder will contribute to:
* 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.
In addition to the primary responsibilities, the Patient Care Coordinator has the following wider responsibilities:
* a. Support the delivery of QOF, incentive schemes, QIPP and other quality or cost-effectiveness initiatives
* a. Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner
* b. Duties may vary from time to time without changing the general character of the post or the level of responsibility
* Duties may vary from time to time without changing the general character of the post or the level of responsibility
Person Specification
Experience
* Experience of working in a healthcare setting or in a public facing role. Excellent customer service skills.
* Primary Care/General Practice experience
* Excellent IT and computer skills including SystmOne experience
Qualifications
* Good standard of secondary education, including Maths and English
* Healthcare related qualification
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.
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