Description
The Proactive Anticipatory Care Neighbourhood Care Coordinator will support the delivery of personalised, proactive, and holistic care within the Primary Care Network. Working as part of a multidisciplinary team, the postholder will coordinate care for a defined caseload of patients, ensuring timely communication, collaboration, and follow-up across health, social care, and community services.
Main duties of the job:
- To support the delivery of personalised, proactive, and holistic care within the Primary Care Network (PCN), working as part of a multidisciplinary team (MDT).
- To be responsible for a caseload of patients aligned to a specific neighbourhood primary care team.
- Ensure the right professionals are involved, notified and prepared for the meetings in advance.
- Produce high quality notes following MDT meetings to include agreed and assigned actions.
- Carry out home visits for assessment, monitoring, and delivery of care as appropriate.
- Participate in the review of patient outcomes and goals over time.
- Act as a central, continuous point of contact for the patient, their relatives/carers and the professionals involved in the care plan.
- Collaborate with community teams, families, carers, and external partners to support coordinated care delivery.
- Effectively signpost patients to appropriate health and wellbeing services that are best placed to meet unmet care needs.
- Work collaboratively with the nursing team and social prescribing team within the PAC service and escalate patients who require more specialised input from those services when required.
- Support the coordination and implementation of personalised care plans reflecting patient preferences, goals, and needs.
- Refer or request referrals on patients behalf to appropriate services that can assist with meeting outstanding care needs.
The post holder will have a key role in supporting the development of our Extended Access and as such will be required to have significant experience of either primary care or development of small or emerging organisations.
Benefits:
- Aligned with NHS Band 4 salary
Person Specification:
- Educated to GCSE level, including English and Mathematics at grade C or above or equivalent.
- Previous experience of working in health or social care sector.
- Evidence of appropriate continuing professional development and education to maintain up to date knowledge.
Desirable:
- Previous experience working as a HCSW.
- Training in coaching, motivational interviewing, or care navigation
- NVQ level 3 in related field.