Job summary
This role will be part of the Multi-Disciplinary Team (MDT) at Haxby
Group. The post holder will contribute to tackling inequalities in health and
social care. This role will suit an enthusiastic
individual who is able to work collaboratively across a team and keen to
deliver within the evolving role of the network.
The Care Co-ordinator
will be part of a team of care coordinators supporting different cohorts of
vulnerable patients including, but not limited to, people with learning disabilities, people with severe mental health illness,
newly diagnosed cancer patients, carers, people from ethnic communities and
people with long term conditions.
The post holder will
work alongside the nursing and medical teams in proactively supporting patients
to engage with annual health checks, developing support plans and signposting
and coordinating support from other agencies to improve inequalities in health.
Candidates please note the interviews for this role will be held on Monday 11 August 2025.
Main duties of the job
- You will support the Clinical Lead Nurse in co-ordinating all key activities including access to services, advice, and information, and ensuring health and care planning is timely, efficient, and patient-centred. This will include supporting the implementation of digital initiatives into primary care including coordinating care for our Learning Disabilities, Serious Mental Illness and Dementia patients and liaising with Carers Plus and identifying Carers. You will also undertake the care coordination of our frailty patients working with a designated Advanced Clinical Practitioner to support the work with our frailty patients, which may involve going out into the community from time to time.
- You will work alongside the Care Home Team to provide support and cover as needed. This will involve improving the continuity of care by acting as a point of contact for residents, families and professionals who visit care homes such as MDT members and in-reach specialists.
- You will handle event planning for national days including Veterans, Dementia Forward, and Carers days along with Notice board management.
- You will network with surgeries within our PCN, helping with the PCN Baby Clinic on a rota basis with other PCN surgeries. This will be off site.
About us
We are a leading primary care organisation that delivers high quality care from GP practices in Scarborough, York and Hull. Innovative and committed, we are at the forefront of developments within our field. We are well organised and deliver high quality care with a range of friendly and supportive staff.
Job description
Job responsibilities
The duties and responsibilities to be undertaken by members of the Care Coordination team may include any or all of the items in the following list. Duties may be varied from time to time under the direction of the Clinical Lead Nurse, dependent on current and evolving workload and staffing levels:
- You will bring together a persons identified care and support needs, and support 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.
- You will support patients to utilise decision aids in preparation for a shared decision-making conversation.
- You will help people to manage their needs through answering queries, prioritising patients for review and ensuring that people have good quality written or verbal information to help them make choices about their care.
- Responsible for supporting people to take up training and employment and to access appropriate benefits where eligible, if appropriate.
- You will support people to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure.
- Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level.
- Explore and assist people to access personal health budgets where appropriate.
- Provide co-ordination and navigation for people, and their relatives and/or carers, across health and care services, working closely with the social prescribing link worker and other primary care professional.
- Support the co-ordination and delivery of MDTs within the practice.
- Demonstrate accountability for delivering professional expertise.
- Raise awareness within the practice of shared decision-making and decision support tools.
- Raise awareness of how to identify patients who may benefit from shared decision-making and support practice staff and patients to be more prepared to have shared decision-making conversations.
- Exercise a critical understanding of personal scope of practice and work with the GPs and other primary care professionals within the practice to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the practice.
- Identify where there are opportunities for developing the scope and competence of the wider MDT to meet patient care needs.
- Through patient assessment and working in partnership with patients and their carers, make decisions about the best pathway of care, informed by the urgency and severity of patient need, patient acuity and dependency, and the most appropriate deployment of resources.
- Manage risk in unpredictable, uncertain situations to uphold patient safety, including by referring on to other primary care team members and to specialist services, as needed.
- Responsible for following legal, ethical, professional and organisational policies/procedures and codes of conduct.
- Involve patients in decision making and supporting adherence as per NICE guidance.
- Operate as a full member of the primary care team, including contributing to leadership, service evaluation/improvement and research activity.
- Manage and co-ordinate the care that individual patients receive, including through liaising with other members of the MDT and with patients' carers.
- Lead primary care activity, with a strong emphasis on prevention and early intervention, including through the delivery of public health advice.
- Undertake, record, and follow guidelines for the tasks for which you have received appropriate training and achieved competency including but not exhaustive which may lead to some biometric testing and offering routine health checks following practice protocols.
- Providing clerical assistance to Practice staff as required from time to time, including word/data processing, filing, photocopying, and scanning.
- Taking messages and passing on information.
- Provision of refreshments for staff and visitors as required, loading, and emptying the dishwasher and keeping the kitchen area clean and tidy.
- Helping to maintain hygiene control measures.
Job description
Job responsibilities
The duties and responsibilities to be undertaken by members of the Care Coordination team may include any or all of the items in the following list. Duties may be varied from time to time under the direction of the Clinical Lead Nurse, dependent on current and evolving workload and staffing levels:
- You will bring together a persons identified care and support needs, and support 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.
- You will support patients to utilise decision aids in preparation for a shared decision-making conversation.
- You will help people to manage their needs through answering queries, prioritising patients for review and ensuring that people have good quality written or verbal information to help them make choices about their care.
- Responsible for supporting people to take up training and employment and to access appropriate benefits where eligible, if appropriate.
- You will support people to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure.
- Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level.
- Explore and assist people to access personal health budgets where appropriate.
- Provide co-ordination and navigation for people, and their relatives and/or carers, across health and care services, working closely with the social prescribing link worker and other primary care professional.
- Support the co-ordination and delivery of MDTs within the practice.
- Demonstrate accountability for delivering professional expertise.
- Raise awareness within the practice of shared decision-making and decision support tools.
- Raise awareness of how to identify patients who may benefit from shared decision-making and support practice staff and patients to be more prepared to have shared decision-making conversations.
- Exercise a critical understanding of personal scope of practice and work with the GPs and other primary care professionals within the practice to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals within the practice.
- Identify where there are opportunities for developing the scope and competence of the wider MDT to meet patient care needs.
- Through patient assessment and working in partnership with patients and their carers, make decisions about the best pathway of care, informed by the urgency and severity of patient need, patient acuity and dependency, and the most appropriate deployment of resources.
- Manage risk in unpredictable, uncertain situations to uphold patient safety, including by referring on to other primary care team members and to specialist services, as needed.
- Responsible for following legal, ethical, professional and organisational policies/procedures and codes of conduct.
- Involve patients in decision making and supporting adherence as per NICE guidance.
- Operate as a full member of the primary care team, including contributing to leadership, service evaluation/improvement and research activity.
- Manage and co-ordinate the care that individual patients receive, including through liaising with other members of the MDT and with patients' carers.
- Lead primary care activity, with a strong emphasis on prevention and early intervention, including through the delivery of public health advice.
- Undertake, record, and follow guidelines for the tasks for which you have received appropriate training and achieved competency including but not exhaustive which may lead to some biometric testing and offering routine health checks following practice protocols.
- Providing clerical assistance to Practice staff as required from time to time, including word/data processing, filing, photocopying, and scanning.
- Taking messages and passing on information.
- Provision of refreshments for staff and visitors as required, loading, and emptying the dishwasher and keeping the kitchen area clean and tidy.
- Helping to maintain hygiene control measures.
Person Specification
Competencies/Qualities/Attributes
Essential
- An interest in primary care
- Good communication (written and verbal)
- Work well under pressure
- Able to work as a team member
- Able to work unsupervised
- Able to use own initiative
- Be self-motivated
- Able to listen and empathise
- Negotiation and conflict resolution skills
- Hard working and willing
- Flexible and adaptable, able to work according to changing need
- Enthusiastic
- Commitment to CPD
Physical Requirements
Essential
- Able to undertake the requirements of the post
- Reliable
- Flexible
- Excellent attendance record
Desirable
Knowledge/Qualifications/Skills
Essential
- NVQ Level 2/3 Health and Social Care or Business Administration (or relevant experience)
- Understanding of human needs physical, emotion social
- Ability to recognise and manage risk
- Understanding of working with confidential information and an understanding of service user confidentiality
- The needs of vulnerable adults, safeguarding and the associated legislative framework
- Understanding of basic health and social care terminology
- Working in a multi-disciplinary setting
- Working with vulnerable groups of people.
- Understanding of health and social care processes
- Ability to communicate confidently with staff of all seniority levels
- Developing relationships with a wide variety of people
- Ability to deliver successful outcomes within determined timeframes
- Continuous CPD and identifying opportunities for self-development
Desirable
- Understanding of the current issues facing the NHS
- Knowledge of social service structures
- Health and social care assessments
Person Specification
Competencies/Qualities/Attributes
Essential
- An interest in primary care
- Good communication (written and verbal)
- Work well under pressure
- Able to work as a team member
- Able to work unsupervised
- Able to use own initiative
- Be self-motivated
- Able to listen and empathise
- Negotiation and conflict resolution skills
- Hard working and willing
- Flexible and adaptable, able to work according to changing need
- Enthusiastic
- Commitment to CPD
Physical Requirements
Essential
- Able to undertake the requirements of the post
- Reliable
- Flexible
- Excellent attendance record
Desirable
Knowledge/Qualifications/Skills
Essential
- NVQ Level 2/3 Health and Social Care or Business Administration (or relevant experience)
- Understanding of human needs physical, emotion social
- Ability to recognise and manage risk
- Understanding of working with confidential information and an understanding of service user confidentiality
- The needs of vulnerable adults, safeguarding and the associated legislative framework
- Understanding of basic health and social care terminology
- Working in a multi-disciplinary setting
- Working with vulnerable groups of people.
- Understanding of health and social care processes
- Ability to communicate confidently with staff of all seniority levels
- Developing relationships with a wide variety of people
- Ability to deliver successful outcomes within determined timeframes
- Continuous CPD and identifying opportunities for self-development
Desirable
- Understanding of the current issues facing the NHS
- Knowledge of social service structures
- Health and social care assessments
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.
