PCN Care Coordinator

Job purpose The PCN Care Co-ordinator will provide practical personalised support to patients whose care involves several professionals or services The postholder will help patients understand the next steps in their care communicate what matters to them and access the support agreed with their clinical team The postholder will maintain a defined caseload coordinate appointments and referrals follow multidisciplinary team actions through to an outcome and raise concerns promptly The Care Co-ordinator will work across Bradford City Five PCN member practices and with the wider PCN multidisciplinary team Patient care and co-ordination Use clinician-approved patient lists practice referrals and multidisciplinary team recommendations to identify and engage patients requiring care co-ordination Contact patients using agreed methods explain the service and identify their priorities communication needs and any barriers to accessing care Maintain an accurate and current caseload including contact dates next actions responsible professionals review dates and outcomes Help patients prepare for conversations with GPs nurses pharmacists and other healthcare professionals Support patients to understand agreed actions and personalised care and support plans ensuring they know who is responsible for each action and what happens next Arrange and track agreed appointments referrals and reviews and help resolve practical barriers that may prevent patients from accessing care Follow up missed appointments and contacts in accordance with agreed PCN and practice procedures Support access to appropriate self-management wellbeing and community services working closely with the PCN Social Prescribing and Health and Wellbeing teams Supporting priority patient groups The postholder will support agreed PCN patient cohorts which may include people with long-term conditions and complex needs This will include supporting patients living with frailty or dementia and their carers to prepare for reviews and ensuring agreed actions are followed up The Care Co-ordinator may also support patients experiencing repeated urgent-care use recent transitions of care difficulties attending appointments or other barriers to accessing healthcare The postholder will support agreed screening vaccination and annual-review activity for patients within their caseload where appropriate Multidisciplinary team working Support the organisation and co-ordination of relevant patient multidisciplinary team discussions Ensure appropriate information is available to support multidisciplinary team discussions through approved secure processes Where possible establish the patient's priorities before their case is discussed Accurately record agreed actions including the responsible professional and expected completion date Track outstanding actions and escalate overdue or rejected referrals appropriately Keep patients appropriately informed about agreed actions and follow-up Work collaboratively with GPs nurses practice teams Social Prescribing Link Workers Health and Wellbeing Coaches Clinical Pharmacists mental health professionals physiotherapists and relevant community and voluntary-sector services Record keeping and information governance Document patient contacts and actions promptly and accurately in SystmOne using agreed PCN and practice templates and codes Maintain confidentiality and comply with PCN and practice information governance data protection and information-sharing requirements Use authorised systems and accounts and only access or share information necessary for the role Verify identity and appropriate carer authority before sharing confidential patient information Provide appropriate anonymised or aggregated activity and outcome information to support PCN monitoring and service development Safety safeguarding and role boundaries This is a non-clinical role The Care Co-ordinator will not diagnose conditions independently assess clinical urgency prescribe medication interpret test results or make changes to a patient's treatment Promptly escalate new symptoms deterioration medication concerns or other clinical concerns to an appropriate clinician Recognise and respond appropriately to safeguarding concerns following local safeguarding procedures Use urgent or emergency escalation routes where required in accordance with local procedures Maintain clear factual records of concerns and actions taken Work within their level of competence and seek advice or supervision whenever a task or situation falls outside their role Follow relevant health and safety infection prevention equality accessibility incident reporting and lone-working procedures Working with our communities The postholder will work respectfully and sensitively with Bradford's diverse communities They will identify patients' preferred language communication method accessibility requirements and safe contact arrangements The postholder will use professional interpreting services through agreed routes where required The Care Co-ordinator will recognise that some patients may experience digital exclusion or other barriers to accessing healthcare and will support appropriate alternative methods of communication and access Training and development Complete an appropriate induction programme and all required mandatory training Undertake or complete the appropriate Care Co-ordination training pathway Participate in regular supervision appraisal and continuing professional development Maintain an appropriate learning and development record Attend relevant PCN practice and multidisciplinary meetings Identify opportunities to improve patient pathways and reduce barriers to accessing care Contribute to patient and practice feedback and service improvement Service development The postholder will help colleagues understand the Care Co-ordination referral pathway and appropriate use of the service They will contribute to the development of safe and effective processes for managing referrals caseloads multidisciplinary team actions follow-up and handover arrangements The role will continue to develop in response to the needs of patients and the PCN Any additional duties will be reasonable and consistent with the purpose level training and responsibilities of the Care Co-ordinator role Management and accountability The postholder will report to the PCN Manager and work within the governance arrangements of Bradford City Five PCN Limited The postholder will receive named Care Co-ordination supervision and have access to appropriate clinical support and escalation routes The role will work across the Bradford City Five PCN member practices and agreed community settings