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 are 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 Coordinatorwill 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 adefined caseload of patients within the Ageing Well cohort.
* Coordinate and organise staff rotason SystmOne for ANP, Frailty Nurse, Occupational Therapist and Pharmacistclinics.
* Contact patients via theirpreferred communication method to invite them into the service and arrangeappointments.
* Support seamless transitionsbetween primary, community and secondary care.
* Liaise regularly with GPs, ANPs,pharmacists, social prescribers and community teams to ensure coordinatedcare delivery.
* Actively participate inmultidisciplinary team (MDT) meetings and support preparation andfollow-up actions.
PersonalisedCare & Support Planning
Holistically bringtogether all of a persons identified care and support needs and exploreoptions to meet these within a single personalised care and support plan(PCSP), in line with PCSP best practice, based on what matters to the personfollowing the NHS Comprehensive CareModel. See also YouTube NHS ComprehensivePersonalised Care Model Explainer Animation.
* Conduct home visits for houseboundpatients where appropriate.
* Review and update care plans atagreed intervals.
* Promote shared decision-makingconversations.
* Ensure care plans are communicatedto relevant professionals and recorded accurately in clinical systems.
* Escalate any clinical concerns tosupervising clinician.
Navigation& Signposting
* Develop an in-depth understandingof local health, community and voluntary sector services.
* Support appropriate onwardreferrals to social prescribing link workers and other services.
* Help patients navigate the widerhealth and care system.
* Identify when additional support orintervention is required and raise concerns promptly.
Digital& Data Responsibilities
* Maintain accurate, contemporaneousdocumentation within SystmOne.
* Record activity using appropriateSNOMED/read codes to support reporting and audit.
* Support data quality improvementwithin the Ageing Well service.
* Use digital systems to trackpatient progress and outcomes.
* Contribute to monitoring serviceactivity and performance metrics.
Governance,Safety & Compliance
* Adhere to safeguarding policies Adults & Children and elevate concerns appropriately.
* Follow lone working proceduresduring home visits.
* Maintain patient confidentialityand comply with information governance standards.
* Identify and report risks orincidents in line with PCN policy.
* Participate in clinical supervisionsessions with supervising GP/ANP.
* Work within the defined scope ofthe 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 andnear-miss events.
Maintain a clean, tidy,effective working area at all times
ServiceImprovement & Development
* Identify service gaps and providefeedback to improve delivery.
* Contribute to quality improvementinitiatives within the PCN.
* Support service monitoring throughaccurate recording of interventions and outcomes.
* Assist in evaluation of patientexperience within the service.
ProfessionalDevelopment
* Participate in regular one-to-onesupervision meetings.
* Engage in mandatory training andongoing professional development.
* Take part in annual appraisal andobjective setting.
* Work collaboratively with otherCare Coordinators across the PCN.
Thepost-holder will contribute to:
* Increased completion ofpersonalised care plans.
* Improved frailty identification andcoding accuracy.
* Reduction in avoidable hospitaladmissions where appropriate.
* Improved patient experience andcontinuity of care.
* Effective MDT coordination andfollow-up.
In addition to the primary responsibilities,the Patient Care Coordinator has the following wider responsibilities:
a.Supportthe delivery of QOF, incentive schemes, QIPP and other quality or costeffectiveness initiatives
a.Undertakeany 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.Dutiesmay vary from time to time without changing the general character of the post or the level of responsibility
Duties may vary fromtime to time without changing the general character of the post or the level ofresponsibility
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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