Care Coordinator

The role is responsible for engaging, and supporting individuals, particularly those who are frail,elderly, or living with long-term or multiple conditions, coordinating,navigating, and personalising care across the health and care system. Therole is central to delivering NHS Englands personalised care model, improving continuity of care and outcomes for people with complex needs.

To act as a single, consistent pointof contact for individuals, their families, and carers, ensuring timely accessto well-organised, person-centred support. Bringing together all elements ofan individuals assessed needs into a comprehensive personalised care and support plan, enabling joined up working across primary care, community services, voluntary sector, and wider system partners.

Working in close collaboration with GPs, practice teams, and the wider multidisciplinary team, including social prescribing link workers and health and wellbeing coaches, ensuring individuals changing needs are identified early and responded to effectively.

The role supports proactive care delivery, reduces fragmentation, and strengthens communication across services.

Play a key role in empowering individuals to take an active role in their own health andwellbeing. This includes preparing people for shared decision-making conversations, supporting understanding of health information, and facilitating access to self-management education, peer support, and community-based interventions.

For a second year in a row, Sunderland GP Alliance has been listed in The Sunday Times Best Places to Work and Better Health At Work - Gold Award, offering 33 days annual leave plus many other benefits

Sunderland GP Alliance is owned by the GP Practices of Sunderland and helps GPs work collaboratively for the benefit of patients and staff. We are a not-for-profit organisation, ensuring any surplus is reinvested back into better services for patients.

Sunderland GP Alliance runs three medical practices at New Silksworth Medical Practice, South Hylton Surgery and Monument Surgeries.

MAIN DUTIES AND RESPONSIBILITIES

• Proactively identify people to support their personalised care requirements, using the available decision support aids.
• Telephone triage all incoming referrals to bring together all of apersons identified care and support needs, and explore their options to meetthese via a single personalised care and support plan, or seamlessly refer cases, if necessary, to appropriateprofessionals.
• Help people to manage their needs, answering their queries and supporting them to make appointments or to take up training and employment, andto access appropriate benefits where eligible.
• Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing, including through use of the Patient Activation Measure.
• Raise awareness of shared decision making and decision support tools,and assist people to be more prepared to have a shared decision making conversation.
• Ensure that people have good quality information to help them make choices about their care,
• Assist people to access self-management education courses, peer supportor interventions that support them in their health and wellbeing.
• Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles.
• Maintain accurate records as required, including providing patient-related information for entering Clinical Reporting Systems, within the required time frame
• To be a point of contact for GPpractices, MDT and Social Prescribing Link Workers, as well as a direct linkfor the wider system across the city.
• Support the identification of patients for inclusion in MDTs within
  
  PCNs.
• Support the collection of patient data for analysis of outcome measure for service interpretation and growth

Role Specific Key Tasks

Education

• Promote social prescribing across the PCN, Health & Social Care professionals and the wider system, including its role in self-management,addressing health inequalities and the wider determinants of health.

Referrals

• Receive and action referrals for social prescriptions via agreed systems.
• Provide holistic, personcentredsupport by developing and reviewing personalised care plans, preparing peoplefor shared decision making, and helping them manage their health andwellbeing.
• Work proactively with diverse communities to ensure equal access to community, voluntary and statutory services, including self-management and peer support.
• Follow up with individuals, gather feedback and outcomes, and contribute to service improvement within the PCN.

Community Asset Development

• Support the development and sustainability of community assets by working with VCSE organisations and local groups to ensure accessible, inclusive resources that meet diverse health andwellbeing needs.
• Build strong partnerships with community organisations to ensure safe, timely…