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Star Lane Medical Centre

Practice Care Coordinator

The closing date is 17 June 2025

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Job summary

Practice Care Coordinator

The practice care coordinators is a key role within the primary care team, responsible for ensuring that patients particularly those with long-term conditions, complex health needs, or multi-agency involvement receive personalised, well-coordinated care. The role supports both individual patient care and broader clinical project work, including the delivery of Enhanced Services (ES) targets and quality improvement initiatives.

Main duties of the job

  • Coordinate personalised care for patients with long-term conditions, complex needs, or multiple service involvement.
  • Work closely with the GP and Practice team, ensuring patients receive joined-up, proactive care.
  • Develop and regularly review care plans, ensuring they reflect patients' goal and changing needs.
  • Support the delivery of Enhanced Services (ES) and Quality Improvement targets, including health checks, structured reviews, and long-term condition management.
  • Contribute to clinical and population health projects, supporting planning, implementation, and data tracking.
  • Act as a central point of contact for patients, helping them to navigate services and understand their care.
  • Liaise with community, voluntary, and health services to arrange appropriate support and referrals.
  • Maintain accurate records and use clinical systems to document interventions and outcomes.

This role is vital I helping the practice deliver more integrated, efficient, and patient-centred care, contributing to better health outcome and improved patient satisfaction.

About us

We are a training practice with a friendly team. The Medical Centre is situated in Canning Town, London Borough of Newham. We are also part of the South One Newham Primary Care Network (PCN)

Details

Date posted

28 May 2025

Pay scheme

Other

Salary

Depending on experience £28,000 to £29,500

Contract

Permanent

Working pattern

Full-time

Reference number

A2741-25-0002

Job locations

121 Star Lane

Canning Town

Newham

E16 4QH


Job description

Job responsibilities

1. Personalised Care Coordinators

manage a defined caseload patients requiring proactive and ongoing care coordination.

work directly with patients and carers to co-produce personalised care and support plans using agreed assessment tools and templates

Act as a consistent point of contact, helping patients navigate their care journey, including before and after clinical appointments.

2. Multidisciplinary Collaboration

Work is part of the multidisciplinary team (MDT), collaborating with GPs, nurses, pharmacist, social prescribers, health coaches, community and secondary care teams.

Facilitate communication and coordination between services to support safe, effective and joined-up care.

3. Clinical Project Support

Assist in the planning, implementation, and evaluation of clinical and quality improvement projects led by the practise or PCN.

Contribute to population health management initiatives by identifying and targeting cohorts of patients for proactive interventions (e.g., hypertension, diabetes, frailty).

work with the clinical team to trial and embed new care models and pathways.

4. Enhanced Services Delivery

support the practise in meeting Enhanced Services (ES) and Direct Enhanced Services (DES) requirements, such as:

o structured medication reviews(SMRs)

o Care planning for patients with learning disabilities, mental health conditions, and severe frailty

o Support for anticipatory care and cancer reviews

o Data collection and patient engagement related to annual recall programmes and IIF (investment and impact fund) indicators

  • track progress against ES targets and assist with the submission of accurate data to commissions.

5. Monitoring and Follow-up

Maintain and review personalised care plans at regular intervals, ensuring they reflect changing needs and preferences

Use practise clinical system (e.g., EMIS) To document intervention, flag key updates, and support accurate coding.

6. Community and self-management support

Signpost patients to relevant local services, support groups, and self-management resources.

Promote independence and help literacy by supporting patients to understand their condition and care options.

Job description

Job responsibilities

1. Personalised Care Coordinators

manage a defined caseload patients requiring proactive and ongoing care coordination.

work directly with patients and carers to co-produce personalised care and support plans using agreed assessment tools and templates

Act as a consistent point of contact, helping patients navigate their care journey, including before and after clinical appointments.

2. Multidisciplinary Collaboration

Work is part of the multidisciplinary team (MDT), collaborating with GPs, nurses, pharmacist, social prescribers, health coaches, community and secondary care teams.

Facilitate communication and coordination between services to support safe, effective and joined-up care.

3. Clinical Project Support

Assist in the planning, implementation, and evaluation of clinical and quality improvement projects led by the practise or PCN.

Contribute to population health management initiatives by identifying and targeting cohorts of patients for proactive interventions (e.g., hypertension, diabetes, frailty).

work with the clinical team to trial and embed new care models and pathways.

4. Enhanced Services Delivery

support the practise in meeting Enhanced Services (ES) and Direct Enhanced Services (DES) requirements, such as:

o structured medication reviews(SMRs)

o Care planning for patients with learning disabilities, mental health conditions, and severe frailty

o Support for anticipatory care and cancer reviews

o Data collection and patient engagement related to annual recall programmes and IIF (investment and impact fund) indicators

  • track progress against ES targets and assist with the submission of accurate data to commissions.

5. Monitoring and Follow-up

Maintain and review personalised care plans at regular intervals, ensuring they reflect changing needs and preferences

Use practise clinical system (e.g., EMIS) To document intervention, flag key updates, and support accurate coding.

6. Community and self-management support

Signpost patients to relevant local services, support groups, and self-management resources.

Promote independence and help literacy by supporting patients to understand their condition and care options.

Person Specification

Experience

Essential

  • Experience in a care coordination, administrative, or patient-facing healthcare role.
  • Strong organisational skills and the ability to manage multiple priorities.
  • Confident IT skills with experience in clinical systems and data reporting
  • excellent communication, empathy, and relationship building abilities.
  • Understanding of person-centred care and the challenges faced by those with complex or long-term needs.

Desirable

  • Experience supporting enhance services, QOF, or DES deliveries.
  • Familiarity with NHS care coordination models and personalised care approaches.
  • Involvement in audit, project delivery, or quality improvement within healthcare.
Person Specification

Experience

Essential

  • Experience in a care coordination, administrative, or patient-facing healthcare role.
  • Strong organisational skills and the ability to manage multiple priorities.
  • Confident IT skills with experience in clinical systems and data reporting
  • excellent communication, empathy, and relationship building abilities.
  • Understanding of person-centred care and the challenges faced by those with complex or long-term needs.

Desirable

  • Experience supporting enhance services, QOF, or DES deliveries.
  • Familiarity with NHS care coordination models and personalised care approaches.
  • Involvement in audit, project delivery, or quality improvement within healthcare.

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.

Employer details

Employer name

Star Lane Medical Centre

Address

121 Star Lane

Canning Town

Newham

E16 4QH


Employer's website

https://www.starlanemedicalcentre.nhs.uk (Opens in a new tab)

Employer details

Employer name

Star Lane Medical Centre

Address

121 Star Lane

Canning Town

Newham

E16 4QH


Employer's website

https://www.starlanemedicalcentre.nhs.uk (Opens in a new tab)

Employer contact details

For questions about the job, contact:

HR

Portia Corcho

hr.slmc@nhs.net

02074764862

Details

Date posted

28 May 2025

Pay scheme

Other

Salary

Depending on experience £28,000 to £29,500

Contract

Permanent

Working pattern

Full-time

Reference number

A2741-25-0002

Job locations

121 Star Lane

Canning Town

Newham

E16 4QH


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