# LTC Proactive Care Coordinator **Company**: Hornchurch Healthcare **Location**: Hornchurch **Job type**: Fixed term **Salary**: £29000.00 to £33000.00 **Category**: Healthcare **Industry**: Healthcare **Apply**: https://www.jobs.nhs.uk/candidate/jobadvert/A5575-26-0001?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply **Canonical**: https://yubhub.co/jobs/job_dc6c14c0-cfd ## Description Havering Liberty Primary Care Network is seeking an organised, compassionate and proactive Care Coordinator to support patients living with long-term conditions. Working across our PCN practices, you will coordinate MDT meetings, manage patient call and recall processes, maintain accurate EMIS records and help patients access timely reviews, personalised care planning and wider community support. This is an excellent opportunity for someone with strong communication, IT and organisational skills who is passionate about improving patient outcomes and reducing health inequalities. **Main duties of the job** The LTC Proactive Care Coordinator will support delivery of the NEL Long Term Conditions (LTC) Proactive Care Quality and Outcomes Framework. The post holder will coordinate proactive care activities for identified patient cohorts, facilitate multidisciplinary team (MDT) meetings, undertake call and recall processes, maintain accurate clinical records using EMIS, and support achievement of the LTC Local Incentive Scheme (LIS) requirements and outcomes. The role will ensure patients receive timely reviews, personalised care planning and coordinated support, contributing to improved health outcomes, reduced health inequalities and enhanced patient experience. **Key Duties and Responsibilities include:** - MDT Coordination - Call and Recall Processes - EMIS administration and data quality - Care planning support - Performance and reporting **MDT Coordination** - Organise and coordinate regular LTC MDT meetings at practice, PCN or neighbourhood level. - Prepare patient lists and case summaries for discussion. - Record actions, outcomes and agreed care plans from MDT meetings. - Track completion of MDT actions and follow up with relevant clinicians and services. - Liaise with community, mental health, social care, voluntary sector and secondary care partners as required. - Ensure MDT discussions support personalised and holistic care planning. **Call and Recall Processes** - Identify eligible patients for LTC reviews using approved searches and cohort criteria. - Operate systematic call and recall processes for annual reviews, care planning appointments and follow-up interventions. - Contact patients via telephone, SMS, letters and other approved communication channels. - Monitor uptake and non-attendance and take appropriate follow-up action. - Maintain accurate records of invitations, appointments and outcomes. **EMIS Administration and Data Quality** - Maintain and update patient records using EMIS. - Apply agreed LTC templates and care planning tools. - Ensure appropriate clinical coding and recording of care plan activity, wider determinants of health, personalised care discussions and MDT outcomes. - Support data quality improvement by identifying coding gaps and outstanding actions. - Run EMIS searches and reports to support performance monitoring and service delivery. - Ensure information is recorded in accordance with PCN, ICB and information governance requirements **Care Planning Support** - Support delivery of the Year of Care approach. - Assist patients to access appropriate services, including social prescribing, community services and self-management support. - Ensure care plans reflect patient goals, preferences and identified needs. - Support identification and recording of wider determinants of health. **Performance and Reporting** - Monitor progress against LTC LIS targets and outcomes. - Produce reports on call and recall activity, review completion rates and MDT outcomes. - Escalate risks relating to performance, patient engagement or service delivery. - Support practices and PCN teams to achieve contractual and quality requirements ## Skills ### Required - EMIS - Microsoft Office - communication skills - organisational skills - interpersonal skills ### Nice to have - MDT administration and minute taking - Knowledge of LTC management programmes - QOF/LIS requirements - Understanding of personalised care and care planning - Population health management and data reporting - Knowledge and ability to use GP IT system EMIS Web --- Source: [Apply at jobs.nhs.uk](https://www.jobs.nhs.uk/candidate/jobadvert/A5575-26-0001?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply)