PCN Care CoodinatorNHS

Job summary

We are seeking an enthusiastic and organised Care Coordinators to join the growing multi-disciplinary team within the North Wilts Border PCN. Building on our successful care coordination model, this role is key to delivering personalised, joined-up care for our patients.

As a Care Coordinator, you will work closely with PCN practices and a wide range of health professionals, including GPs, nurses, paramedics, pharmacists, and others. You will be responsible for coordinating access to services, information, and support ensuring that care is timely, efficient, and centred around the needs of each patient.

This is a vital role that contributes directly to:

• Enhancing patient experience and outcomes
• Preventing avoidable hospital admissions
• Supporting the NHS Long Term Plan and PCN priorities through integrated, person-centred care
• You will act as a key point of contact, helping to bridge the gap between patients and clinical teams.
• Your work will help free up valuable clinical time while ensuring that patients feel informed, supported, and confident in managing their own health and wellbeing.

Main duties of the job

• As a Care Coordinator within the Primary Care Network (PCN), you will play a pivotal role in supporting patients to manage their health and wellbeing.
• You will use population health intelligence to proactively identify patient cohorts and develop personalised care and support plans that address their holistic needs.
• You will work closely with GPs, multidisciplinary team (MDT) members, social prescribing link workers, health and wellbeing coaches, and community services to ensure coordinated and seamless care.
• You will support patients and their carers in navigating the health and social care system, answering queries, arranging and managing appointments, and providing clear verbal and written information to help them make informed choices.
• Additionally, you will coordinate hospital discharges, manage referrals to adult social care, and work collaboratively with community health teams, care homes, and other providers to ensure timely and effective care.
• You will also support the administration and delivery of MDT meetings, monitor and allocate team responsibilities, and maintain an up-to-date directory of local services, charities, and voluntary sector organisations to optimise patient support.
• You will promote patient activation by linking individuals to self-management education, peer support, and interventions that enhance their knowledge, skills, and confidence in managing their health.

Job description

Primary Responsibilities

• Develop and maintain a comprehensive directory of local services, including charities, community and voluntary sector organisations, and relevant private providers, ensuring up-to-date information is available for staff and service users.
• Deliver dedicated support to unpaid carers through carer clinics, offering guidance, signposting, emotional support, and assistance in accessing appropriate services or respite options.
• Coordinate safe and effective hospital discharge processes for patients under and over 75, ensuring timely follow-up care, medication reviews, and clear communication with families and community services.
• Manage referrals to Adult Social Care, liaising closely with social workers to ensure individuals receive timely assessments and appropriate care packages that meet their needs.
• Work collaboratively with community health teams, including District Nurses, Occupational Therapists, and Physiotherapists, to support holistic care planning and facilitate referrals for clinical or functional support.
• Engage Adult Social Care when issues of safeguarding or the need for a care assessment arise, ensuring concerns are escalated appropriately
• Build strong working relationships with care homes and teams supporting housebound patients to promote resident wellbeing, coordinate vaccinations, arrange social prescribing visits, and ensure effective communication between all involved providers.
• Arrange wheelchair assessments and referrals and support individuals in accessing appropriate mobility equipment and adaptations.
• Conduct and coordinate Dementia Reviews, including running assessment clinics, supporting carers, gathering input from GPs and community services, and ensuring follow-up actions are completed.
• Deliver NHS Health Check clinics, overseeing the full process from assessment to coordination of results, referrals, and lifestyle interventions to ensure effective follow-through for patients.
• Manage, monitor, and allocate LWT responsibilities across the team, ensuring timely completion, consistent documentation, and effective workflow coordination.

Secondary Responsibilities

• Work alongside practice teams to streamline care for patients with complex or long-term needs, aiming to smooth their journey through the system and accelerate access to appropriate support.
• Use agreed clinical criteria and population health management tools to flag individuals who would benefit from coordinated care, ensuring proactive rather than reactive support.
• Respond to patient queries and provide clear, accessible information that helps them understand and manage their health and care plans.
• Arrange patient appointments as needed and promote vaccination uptake among eligible groups to support prevention and early intervention.
• Tailor support to each person's priorities, ensuring care is sensitive to cultural background, personal values, disabilities and long-term conditions
• Coordinate transitions between different parts of the health and care system, ensuring referrals are timely and that patients move smoothly between services without gaps in support.
• Hold a defined caseload and act as a consistent point of contact for patients across primary care, community services, secondary care and care home environments
• Oversee referrals to clinical and non-clinical services, maintaining effective communication with internal healthcare teams and wider partner organisations.
• Provide calm, practical support to people who feel overwhelmed or uncertain about navigating the care system, helping them build confidence and reduce distress.
• Address health inequalities through focused work with priority groups, including people with multiple health needs or those at higher risk of poor outcomes.

About us

North Wilts Border PCN is a vibrant, forward-thinking Primary Care Network serving over 56,000 patients across North Wiltshire and the borders of Swindon. Our network brings together six GP practices

• Malmesbury Primary Care Centre,
• New Court Surgery,
• Purton Surgery,
• Cricklade Surgery,
• The Tolsey Surgery, and
• Tinkers Lane Surgery

To deliver integrated, patient-centred care. By working together, we provide more coordinated, accessible, and flexible services that go beyond traditional GP appointments.

Our multidisciplinary team consisting of GPs, paramedics, clinical pharmacists, care coordinators, and social prescribing link workers.

Together, we support patients medical, social, and wellbeing needs, ensuring holistic care across our network.

This is your chance to join a collaborative environment where innovation, teamwork, and patient care come first.

NOTE: Right to Work in the UK

Please note that we are unable to offer visa sponsorship for this role. Applicants MUST already have the right to work in the UK in order to be considered

What We Offer:

• A supportive and inclusive team culture that is well-led
• Opportunities for professional development and leadership
• Flexible working arrangements
• Access to mentorship and clinical supervision
• Involvement in innovative projects and service development
• Employee Assistant programme
• NHS Pension
• Cost coverage of an Enhanced DBS
• Excellent Induction
• 25 days annual leave pro rata