PCN Patient Care Coordinator Ageing Well Service

PCN Patient Care Coordinator Ageing Well Service

Are you passionate about making a real difference to older people and those living in care homes? Do you thrive on bringing people 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 wider multidisciplinary team, you will proactively manage a caseload of patients with complex or changing needs.

You will join a supportive,collaborative team committed to improving outcomes for vulnerable patients while offering structured supervision and opportunities for development.

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.

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.

The Care Coordinator will support the delivery of the Ageing Well service within the Primary Care Network, working proactively with patients living with frailty, long-term conditions and complex health and social needs.

Clinical Coordination & Caseload Management

• Proactively identify and manage adefined caseload of patients within the Ageing Well cohort.
• Coordinate and organise staff rotason Systm One 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 andfollow-up actions.

Personalised Care & Support Planning

Holistically bring 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 You Tube NHS Comprehensive Personalised Care Model Explainer Animation.

• Conduct home visits for housebound patients where appropriate.
• Review and update care plans atagreed intervals.
• Promote shared decision-makingconversations.
• 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 Systm One.
• 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…