Job summary
Arbennek PCN is looking for an innovative and highly motivated person to join its team as a Care Coordinator.
The role, whilst supporting digital initiatives within the practice and PCN will be vital in ensuring that patients receive the best possible care and service supporting the coordination of all key activity including access to services, advice and information whilst ensuring that patient care planning is patient centered and timely.
Main duties of the job
- Proactively identify and work with a cohort of patients to support their personalised care requirements
- Provide coordination and navigation support using digital tools to help patients access appropriate services
- Develop and maintain personalised care and support plans based on an individuals needs and what matters to them.
- Promote preventative heath care and continuity of care.
About us
Arbennek PCN is located in the central ICA within the Cornwall and Isles of Scilly Integrated Care System and has approximately 32,453 people registered from 4 GP Practices Brannel Surgery, Clays Surgery, Probus Surgery and Roseland Surgeries.
The post holder will work a majority of their time out of The Clays Practice based in Roche.
Details
Date posted
02 June 2025
Pay scheme
Other
Salary
Depending on experience
Contract
Permanent
Working pattern
Full-time
Reference number
A5259-25-0000
Job locations
Victoria Road
Roche
Cornwall
PL26 8JF
Job description
Job responsibilities
Job Purpose
The Care Coordinator role is seen as a critical and evolving post to support the multi-disciplinary teams (MDTs) within the PCN to deliver effective, co-ordinated and personalised care for patients in care homes and for a cohort of elderly and frail patients.
The post holder will work closely with teams to help and support the multi-disciplinary team (MDT) this will include the on-going patient case management. This will involve working with the GP surgeries and linking in with a range of community health and social care services, care homes and third party services.
The post holder will demonstrate excellent organisational and communication skills, be flexible in their approach, able to exercise initiative and demonstrate consistently high standards of professionalism. The post holder must at all times be aware of the need for confidentiality and integrity. They will also need a basic knowledge of Health and Social Care terminology and eligibility criteria and current team structures and pathways.
Key working relationships
Patients, patients families and carers
GPs, nurses and other practice staff
Care home managers, clinicians, carers and staff
Case Manager and Geriatrician
Community nurses and other allied health professionals
Community pharmacists and support staff
Responsibilities underpinning the role
The Care Coordinator has the following key responsibilities, in delivering health services:
To assist the team to develop one single personalised care and support plan for patients to be held on the patients medical records and in the care homes. Holistically bring together all of a patients identified care and support needs, and explore options to meet these with a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person.
To assist the team to develop one single personalised care and support plan for patients to be held on the patients medical records and in the care homes. Holistically bring together all of a patients identified care and support needs, and explore options to meet these with a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person.
Help patients to manage their needs by answering queries, assisting with making/ managing appointments, and ensuring that patients have good verbal or written information to help them make choices about their care.
Provide coordination and navigation for patients and their carers across health and social care services, working closely with social prescribing link workers and other primary care professionals. Explore and assist people to access personal health budgets or appropriate benefits where eligible.
Support patients to utilise decision aids in preparation for a shared decision making conversation.
Work with GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer patients back to other health professionals within the PCN.
Raise awareness within the PCN of shared decision making and decision support tools. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision making conversations.
To act as first point of contact for professionals, GPs, care homes, community services and the third sector.
Responsible for the organisation of MDT meetings and supporting the coordination and delivery of MDTs within the PCN.
Responsible for a register of patients identified at PCN MDT coordinating patient care across services and the PCN.
Review discharge summaries and conduct post discharge follow up call to review patients needs and arrange a package of care if needed.
Manage the recall of patients in need of bloods/BPs and other diagnostic test for medication reviews and/or green eclipse alerts.
To act as a support contact for elderly and frail patients.
To support end of life care and palliative care.
To provide support for patients with learning disabilities.
To follow appropriate safeguarding procedures.
Administrative Reponsibilities
To work as a key member of the MDT to help support the development of effective MDT meetings.
To take a lead in IT ensuring all MDT staff have access to Microsoft Teams and have adequate equipment to participate in video meetings.
Lead on the IT facilitation of the MDT meetings using Microsoft teams including sending out invites to appropriate members of the MDT.
To take minutes of MDT meetings and ensure that action points identified are recorded and followed up within a set timescale.
Under guidance from their line manager take initiative in the organisation and administration of MDT working to minimise the demands upon the multidisciplinary team.
To work with the wider MDT to identify appropriate case managers* for high-risk patients to ensure that patients are reviewed, and anticipatory care plans are developed
Ensure that all patients Anticipatory Care Plans, diagnostics results and associated correspondence are available to the MDT, liaising with all agencies as appropriate, accessing IT systems to ensure relevant information is available
To liaise with acute hospitals and coordinate the sharing of key information between the acute hospital teams and the MDT team.
Act as a non-clinical contact for the care home to assist with case management of patients at risk of admission; working with the ANP / GP to identify sources of support in liaison with case managers.
To accurately read code and update/maintain patients records for anticipatory care.
To update care plan templates within Systm1 ensuring accuracy with read codes used.
Maintain an accurate record of two week wait referrals for practice audits.
To provide support with safeguarding admin (adults and child).
Under the guidance of case managers assist with the discharge process to reduce length of stay in the acute / community hospital setting
This list is not exhaustive and may be subject to change.
Workforce Responsibility
The post holder must remain up to date with mandatory training as required
Environmental Factors
The post holder will be required to drive
The post holder may be required to undertake duties at any location in the community in order to meets service needs
Concentration required for data analysis, tracking patients and meetings, frequent interruptions requiring attention and re-prioritisation of work
Input data for a significant period
Equal Opportunities
Arbennek Healthcare is committed to an equal opportunities policy that affirms that all staff should be afforded equality of treatment and opportunity in employment irrespective of sexuality, marital status, race, religion/belief, ethnic origin, age, or disability. All staff are required to observe this policy in their behaviour to fellow employees.
Confidentiality
All employees are required to observe the strictest confidence with regard to any patient/client information that they may have access to, or accidentally gain knowledge of, in the course of their duties.
All employees are required to observe the strictest confidence regarding any information relating to the work of Arbennek Healthcare and its employees. You are required not to disclose any confidential information either during or after your employment with Arbennek Healthcare, other than in accordance with the relevant professional codes.
Failure to comply with these regulations whilst in the employment of Arbennek Healthcare could result in action being taken.
Data Protection
All employees must adhere to the Arbennek Healthcare Policy on the Protection and use of Personal Information, which provides guidance on the use and disclosure of information. The practices of North Cornwall Coast also have a range of policies for the use of computer equipment and computer-generated information. These policies detail the employees legal obligations and include references to current legislation.
Health and safety
Arbennek Healthcare expects all staff to have a commitment to promoting and maintaining a safe and healthy environment and be responsible for their own and others welfare.
Risk Management
You will be responsible for adopting the risk management culture and ensuring that you identify and assess all risks to your systems, processes and environment and report such risks for inclusion within the risk register of the practices of Arbennek Healthcare. You will also attend mandatory and statutory training, report all incidents/accidents, including near misses, and report unsafe occurrences as laid down within the Incidents and Accidents Policy.
Other duties
The above job description is designed to give an overview of the tasks and responsibilities for this position; it is not intended to be exhaustive. The Strategic Manager will meet annually with the post holder to review and ensure that this position remains relevant and in accordance with the evolving needs of the PCN.
Job description
Job responsibilities
Job Purpose
The Care Coordinator role is seen as a critical and evolving post to support the multi-disciplinary teams (MDTs) within the PCN to deliver effective, co-ordinated and personalised care for patients in care homes and for a cohort of elderly and frail patients.
The post holder will work closely with teams to help and support the multi-disciplinary team (MDT) this will include the on-going patient case management. This will involve working with the GP surgeries and linking in with a range of community health and social care services, care homes and third party services.
The post holder will demonstrate excellent organisational and communication skills, be flexible in their approach, able to exercise initiative and demonstrate consistently high standards of professionalism. The post holder must at all times be aware of the need for confidentiality and integrity. They will also need a basic knowledge of Health and Social Care terminology and eligibility criteria and current team structures and pathways.
Key working relationships
Patients, patients families and carers
GPs, nurses and other practice staff
Care home managers, clinicians, carers and staff
Case Manager and Geriatrician
Community nurses and other allied health professionals
Community pharmacists and support staff
Responsibilities underpinning the role
The Care Coordinator has the following key responsibilities, in delivering health services:
To assist the team to develop one single personalised care and support plan for patients to be held on the patients medical records and in the care homes. Holistically bring together all of a patients identified care and support needs, and explore options to meet these with a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person.
To assist the team to develop one single personalised care and support plan for patients to be held on the patients medical records and in the care homes. Holistically bring together all of a patients identified care and support needs, and explore options to meet these with a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person.
Help patients to manage their needs by answering queries, assisting with making/ managing appointments, and ensuring that patients have good verbal or written information to help them make choices about their care.
Provide coordination and navigation for patients and their carers across health and social care services, working closely with social prescribing link workers and other primary care professionals. Explore and assist people to access personal health budgets or appropriate benefits where eligible.
Support patients to utilise decision aids in preparation for a shared decision making conversation.
Work with GPs and other primary care professionals within the PCN to identify and manage a caseload of patients, and where required and as appropriate, refer patients back to other health professionals within the PCN.
Raise awareness within the PCN of shared decision making and decision support tools. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision making conversations.
To act as first point of contact for professionals, GPs, care homes, community services and the third sector.
Responsible for the organisation of MDT meetings and supporting the coordination and delivery of MDTs within the PCN.
Responsible for a register of patients identified at PCN MDT coordinating patient care across services and the PCN.
Review discharge summaries and conduct post discharge follow up call to review patients needs and arrange a package of care if needed.
Manage the recall of patients in need of bloods/BPs and other diagnostic test for medication reviews and/or green eclipse alerts.
To act as a support contact for elderly and frail patients.
To support end of life care and palliative care.
To provide support for patients with learning disabilities.
To follow appropriate safeguarding procedures.
Administrative Reponsibilities
To work as a key member of the MDT to help support the development of effective MDT meetings.
To take a lead in IT ensuring all MDT staff have access to Microsoft Teams and have adequate equipment to participate in video meetings.
Lead on the IT facilitation of the MDT meetings using Microsoft teams including sending out invites to appropriate members of the MDT.
To take minutes of MDT meetings and ensure that action points identified are recorded and followed up within a set timescale.
Under guidance from their line manager take initiative in the organisation and administration of MDT working to minimise the demands upon the multidisciplinary team.
To work with the wider MDT to identify appropriate case managers* for high-risk patients to ensure that patients are reviewed, and anticipatory care plans are developed
Ensure that all patients Anticipatory Care Plans, diagnostics results and associated correspondence are available to the MDT, liaising with all agencies as appropriate, accessing IT systems to ensure relevant information is available
To liaise with acute hospitals and coordinate the sharing of key information between the acute hospital teams and the MDT team.
Act as a non-clinical contact for the care home to assist with case management of patients at risk of admission; working with the ANP / GP to identify sources of support in liaison with case managers.
To accurately read code and update/maintain patients records for anticipatory care.
To update care plan templates within Systm1 ensuring accuracy with read codes used.
Maintain an accurate record of two week wait referrals for practice audits.
To provide support with safeguarding admin (adults and child).
Under the guidance of case managers assist with the discharge process to reduce length of stay in the acute / community hospital setting
This list is not exhaustive and may be subject to change.
Workforce Responsibility
The post holder must remain up to date with mandatory training as required
Environmental Factors
The post holder will be required to drive
The post holder may be required to undertake duties at any location in the community in order to meets service needs
Concentration required for data analysis, tracking patients and meetings, frequent interruptions requiring attention and re-prioritisation of work
Input data for a significant period
Equal Opportunities
Arbennek Healthcare is committed to an equal opportunities policy that affirms that all staff should be afforded equality of treatment and opportunity in employment irrespective of sexuality, marital status, race, religion/belief, ethnic origin, age, or disability. All staff are required to observe this policy in their behaviour to fellow employees.
Confidentiality
All employees are required to observe the strictest confidence with regard to any patient/client information that they may have access to, or accidentally gain knowledge of, in the course of their duties.
All employees are required to observe the strictest confidence regarding any information relating to the work of Arbennek Healthcare and its employees. You are required not to disclose any confidential information either during or after your employment with Arbennek Healthcare, other than in accordance with the relevant professional codes.
Failure to comply with these regulations whilst in the employment of Arbennek Healthcare could result in action being taken.
Data Protection
All employees must adhere to the Arbennek Healthcare Policy on the Protection and use of Personal Information, which provides guidance on the use and disclosure of information. The practices of North Cornwall Coast also have a range of policies for the use of computer equipment and computer-generated information. These policies detail the employees legal obligations and include references to current legislation.
Health and safety
Arbennek Healthcare expects all staff to have a commitment to promoting and maintaining a safe and healthy environment and be responsible for their own and others welfare.
Risk Management
You will be responsible for adopting the risk management culture and ensuring that you identify and assess all risks to your systems, processes and environment and report such risks for inclusion within the risk register of the practices of Arbennek Healthcare. You will also attend mandatory and statutory training, report all incidents/accidents, including near misses, and report unsafe occurrences as laid down within the Incidents and Accidents Policy.
Other duties
The above job description is designed to give an overview of the tasks and responsibilities for this position; it is not intended to be exhaustive. The Strategic Manager will meet annually with the post holder to review and ensure that this position remains relevant and in accordance with the evolving needs of the PCN.
Person Specification
Qualifications
Essential
- Qualified NVQ level 2 (or equivalent) Health and Social care
- Minimum of 2 years experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field
- Experience of administrative duties
- Computer literate and proficient in the use of Microsoft packages and other software.
- Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality.
- Able to prioritise and manage own workload
- Able to deal with service users sensitively
- Able to work as part of team
- Strong analytical and judgement skills.
- Conscientious, hardworking and self-motivated to work with minimal supervision
- Professional attitude and assertive approach
- Committed to development both personally and for the organisation
- Ability to meet deadlines and work under pressure
- Clean driving license
Desirable
- Qualified NVQ level 3 (or equivalent) Health and Social care
- Experience of arranging meetings/ minute taking
- Experience providing signposting and advice
- Understanding of health and social care processes
Person Specification
Qualifications
Essential
- Qualified NVQ level 2 (or equivalent) Health and Social care
- Minimum of 2 years experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field
- Experience of administrative duties
- Computer literate and proficient in the use of Microsoft packages and other software.
- Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality.
- Able to prioritise and manage own workload
- Able to deal with service users sensitively
- Able to work as part of team
- Strong analytical and judgement skills.
- Conscientious, hardworking and self-motivated to work with minimal supervision
- Professional attitude and assertive approach
- Committed to development both personally and for the organisation
- Ability to meet deadlines and work under pressure
- Clean driving license
Desirable
- Qualified NVQ level 3 (or equivalent) Health and Social care
- Experience of arranging meetings/ minute taking
- Experience providing signposting and advice
- Understanding of health and social care processes
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
The Clays Practice
Address
Victoria Road
Roche
Cornwall
PL26 8JF
Employer's website
Employer details
Employer name
The Clays Practice
Address
Victoria Road
Roche
Cornwall
PL26 8JF
Employer's website
Employer contact details
For questions about the job, contact:
Details
Date posted
02 June 2025
Pay scheme
Other
Salary
Depending on experience
Contract
Permanent
Working pattern
Full-time
Reference number
A5259-25-0000
Job locations
Victoria Road
Roche
Cornwall
PL26 8JF