Care Co-ordinatorNHS

Job summary

The Care Coordinator will work 25 hours per week supporting patients to access appropriate health, social care and community services while promoting personalised care. The role includes coordinating patient reviews, managing referrals, supporting carers, updating patient records, facilitating MDT working, delivering patient education and peer support groups, and signposting patients to local services. The post holder will work closely with practice staff, community organisations and external agencies to improve patient outcomes, support health promotion initiatives, maintain accurate records, and contribute to service development. They will complete Personalised Care Institute training and work towards becoming the Practice Champion for Carers, Learning Disabilities and Veterans.

Main duties of the job

• Review discharge information and undertake patient follow-up contacts where appropriate.
• Support the completion and monitoring of long-term condition and wellbeing assessments.
• Facilitate effective communication between primary care, community services, and partner organisations.
• Organise and coordinate multidisciplinary meetings and community support activities.
• Promote access to local support services, wellbeing programmes, and community resources.
• Develop and distribute patient information, self-management resources, and health promotion materials.
• Lead and facilitate patient engagement activities, including support groups and educational sessions.
• Maintain community resource information and promote opportunities that support patient wellbeing.
• Support the delivery of local projects, campaigns, and outreach initiatives.
• Ensure appropriate recording of patient information, reasonable adjustments, and care home-related activity.
• Contribute to quality improvement, patient safety reporting, and service development activities.
• Undertake relevant training and development to support specialist champion roles within the practice.

Job description

Clinical Responsibilities - Review discharge summaries and conduct courtesy calls - Complete cancer care reviews - Check dementia reviews are completed - Update patient records with completed assessments from external resources (e.g., dementia reviews) Communication and Coordination - Respond to tasks and emails sent internally and externally - Liaise with colleagues regarding internal and external referrals - Attend and arrange MDT meetings - Liaise with Reception with community boards Referral Management - Source and implement referrals to external teams (e.g., Staying Well program, Everyone Health) - Support MPFT, PCN, and other services with local events - Supporting outside agencies, setting up drop-in meetings Patient Support and Education - Post text, email, leaflets, and self-help guides to patients - Conduct monthly peer support group - Lead in facilitating and producing presentations for group clinic - Organise delivery of care choices booklets and other literature - Promote digital tools Carer and Community Support - Identify and support carers - Keep community activities board updated - Attend local networking events - Monitor local services - Projects with signposting patients Administrative Duties - Annual review of registers - Keep contact telephone numbers list up to date - Identify health and local campaigns - Identify and attend appropriate training sessions - Utilise IT applications for information - Send appropriate batch texts to selected groups - Updating reasonable adjustments - Care home coding - Reporting to LFPSE

Complete Personalised Care institute 2 Day training course.

Work towards training to become:

• Carers champion for the practice - Learning disability champion for the practice - Veterans champion for the practice

About us

Balance Street is anestablished NHS GP practice proudly serving the community of Uttoxeter and surrounding areas of Staffordshire. We provide care for approximately 14,500 registered patients, delivering safe, effective, and compassionate healthcare tailored to individual needs. Our practice is guided by core values of respect, kindness, professionalism, teamwork, and continuous learning, which underpin our commitment to high standards of patient care and staff wellbeing. The practice is led by 5 GP partners and supported by a skilled and dedicated team of 46 employed staff, including clinical, nursing, administrative, and support colleagues, all working collaboratively within the wider NHS and Primary Care Network. We offer a comprehensive range of services, including general medical services, long-term condition management, health promotion and disease prevention, immunisations and vaccinations, family planning, minor surgery, mental health support, and enhanced services, ensuring accessible, holistic care for our patients close to home.