Care Coordinator with Digital Systems Coordination

Purpose of the Role The purpose of the role is to support proactive, coordinated and personalised care for patients, particularly those who may otherwise be at risk of being missed by routine systems. The post holder will: • support care coordination for patients with long-term conditions and medication monitoring needs; • help identify patients who require additional support, follow-up or navigation; • support vulnerable patient groups, including housebound patients, care home residents, patients with learning disabilities or other disabilities, and carers; • help improve the accuracy of relevant clinical coding; • support the practice's transition from Ardens-based recall processes to Abtrace; • help develop safe workflows, SOPs and protocols for recall, non-responder management and escalation; • work with clinicians, pharmacists, nurses, administrative teams, social care and community services where appropriate; • support practice staff in using digital systems safely and effectively in relation to care pathways; • help coordinate the practice response when key digital systems are disrupted, to ensure maintenance of patient care; • provide advice and practical recommendations to the Operations Lead and partners on digital workflow issues affecting care coordination, access, safety or efficiency. Main Duties and Responsibilities 1. Care Coordination and Patient Support The post holder will help coordinate care for patients who need proactive support, monitoring or follow-up. Duties will include: • Supporting patients with long-term conditions, medication monitoring needs and complex care requirements. • Helping identify patients who may need more personalised support than standard automated recall. • Contacting patients, carers or care homes where appropriate to help arrange reviews, blood tests, monitoring or follow-up. • Helping patients understand what review or monitoring is needed and how to access it. • Supporting patients who may struggle to use digital booking links, automated recall or standard appointment systems. • Escalating clinical concerns, safeguarding concerns or access difficulties to the appropriate clinician or manager. • Liaising with GPs, nurses, pharmacists, social prescribing colleagues, care homes, carers, community teams and social care professionals where appropriate. • Supporting patients and carers with navigation through practice processes where this improves access, safety or continuity. • Maintaining accurate records of relevant contacts and actions. 2. Recall, Medicines Monitoring and Long-Term Condition Coordination The post holder will help support the practice's recall and monitoring systems. Duties will include: • Supporting the implementation and ongoing use of Abtrace. • Helping the practice move from Ardens-based recall processes to Abtrace workflows. • Supporting recall processes for chronic disease reviews, medication monitoring and planned blood tests. • Monitoring recall lists and identifying patients who are overdue or have not responded. • Helping ensure appropriate appointment availability for recall and monitoring work. • Working with nursing, pharmacy and administrative teams to coordinate recall activity. • Supporting medication monitoring workflows, including shared care monitoring where appropriate. • Helping reduce duplicated or fragmented recall activity. • Supporting the development of SOPs and protocols for recall, non-responder management and escalation. • Identifying where recall processes are not working effectively and suggesting improvements. 3. Support for Vulnerable Patient Groups A key part of the role will be helping the practice identify patients who may need more proactive or personalised care. Duties will include: • Supporting improved coding and identification of housebound patients. • Supporting accurate coding and identification of care home residents. • Supporting improved identification and coding of carers. • Supporting coordination for patients with learning disabilities and other disabilities. • Identifying patients who may not respond to standard digital recall methods. • Helping develop workflows for patients who need additional contact, carer involvement or professional coordination. • Supporting the practice to target additional care, communication and compassion towards patients who are more vulnerable or less able to navigate standard systems. • Working within agreed protocols to ensure concerns are passed to the right clinician, team or external professional. 4. Digital Systems Coordination The post holder will provide practical coordination and oversight for digital systems used within the practice in relation to the coordination of care. Duties may include: • Developing a strong working knowledge of key practice systems including EMIS, Abtrace, AccuRx and BetterLetter. • Acting as a local point of contact for digital workflow queries within the practice. • Helping coordinate the practice response when key clinical or operational systems are disrupted, for example EMIS downtime, to ensure maintenance of patient care. • Supporting the development and maintenance of downtime processes and communication plans. • Liaising with external IT support, suppliers or system providers where appropriate. • Helping staff understand changes to digital systems and workflows in relation to care pathways. • Supporting training for practice staff when systems or processes change. • Helping create simple guides, SOPs and training materials. • Identifying recurring digital workflow problems and suggesting practical solutions. • Advising the Operations Lead and partners on digital system issues affecting patient care, safety, access or efficiency. • Helping ensure digital processes are safe, consistent and understood across the practice. 5. Digital Training and Practice Support The post holder will help improve confidence and consistency in the use of practice systems. Duties may include: • Supporting staff training on agreed digital workflows. • Helping new staff understand relevant digital systems. • Producing quick-reference guides or process notes. • Helping identify where staff need further training or support. • Supporting implementation of new systems or major workflow changes. • Helping ensure changes are communicated clearly to affected teams. • Working with leads and managers to ensure systems are used consistently. • Supporting learning from digital incidents, system outages or workflow failures. 6. Communication and Patient Engagement The post holder will support clear communication with patients and carers, particularly where this relates to recall, monitoring, vulnerable patient groups or access to care. Duties may include: • Supporting patient-facing communication about recall and monitoring processes. • Helping draft clear SMS, email, website or written messages. • Supporting communication campaigns linked to long-term condition reviews, medicines monitoring or patient access. • Helping ensure communication is accessible to patients and carers. • Supporting communication with care homes, carers and other professionals. • Identifying where communication processes are not working well and suggesting improvements. 7. Quality Improvement, Data and Reporting The post holder will support the practice in using data and digital systems to improve care. Duties may include: • Reviewing recall dashboards, reports and patient lists. • Identifying patterns in overdue monitoring, non-response or coding gaps. • Supporting audits linked to recall, medicines monitoring, patient cohorts or digital workflows. • Helping monitor whether recall systems are working as intended. • Supporting quality improvement projects linked to patient access, safety, coding or continuity. • Producing simple reports or summaries for managers and clinicians where required. • Helping identify practical improvements from day-to-day system use. 8. Team Working and Professional Boundaries The post holder will work closely with clinical, administrative and operational teams. Duties will include: • Working collaboratively with GPs, nurses, pharmacists, administrators and managers. • Supporting joined-up working between clinical and non-clinical teams. • Attending relevant meetings and training. • Working within agreed protocols and escalation routes. • Recognising the limits of the role and not giving clinical advice unless specifically trained and authorised. • Escalating clinical, safeguarding or operational concerns appropriately. • Maintaining confidentiality and information governance standards at all times. Training and Development The practice will support the successful candidate with: • Care Coordinator training in line with ARRS requirements. • Training in personalised care and care navigation principles. • System-specific training, including EMIS, Abtrace, AccuRx and BetterLetter. • Information governance and safeguarding training. • Support to develop skills in recall management and population health. • Support to develop skills in digital systems coordination and staff training. • Ongoing supervision from the Operations Lead, management team and clinical partners. The role is expected to evolve as the practice develops its recall, medicines monitoring, chronic disease management and digital systems. Job description Job responsibilities Purpose of the Role The purpose of the role is to support proactive, coordinated and personalised care for patients, particularly those who may otherwise be at risk of being missed by routine systems. The post holder will: • support care coordination for patients with long-term conditions and medication monitoring needs; • help identify patients who require additional support, follow-up or navigation; • support vulnerable patient groups, including housebound patients, care home residents, patients with learning disabilities or other disabilities, and carers; • help improve the accuracy of relevant clinical coding; • support the practice's transition from Ardens-based recall processes to Abtrace; • help develop safe workflows, SOPs and protocols for recall, non-responder management and escalation; • work with clinicians, pharmacists, nurses, administrative teams, social care and community services where appropriate; • support practice staff in using digital systems safely and effectively in relation to care pathways; • help coordinate the practice response when key digital systems are disrupted, to ensure maintenance of patient care; • provide advice and practical recommendations to the Operations Lead and partners on digital workflow issues affecting care coordination, access, safety or efficiency. Main Duties and Responsibilities 1. Care Coordination and Patient Support The post holder will help coordinate care for patients who need proactive support, monitoring or follow-up. Duties will include: • Supporting patients with long-term conditions, medication monitoring needs and complex care requirements. • Helping identify patients who may need more personalised support than standard automated recall. • Contacting patients, carers or care homes where appropriate to help arrange reviews, blood tests, monitoring or follow-up. • Helping patients understand what review or monitoring is needed and how to access it. • Supporting patients who may struggle to use digital booking links, automated recall or standard appointment systems. • Escalating clinical concerns, safeguarding concerns or access difficulties to the appropriate clinician or manager. • Liaising with GPs, nurses, pharmacists, social prescribing colleagues, care homes, carers, community teams and social care professionals where appropriate. • Supporting patients and carers with navigation through practice processes where this improves access, safety or continuity. • Maintaining accurate records of relevant contacts and actions. 2. Recall, Medicines Monitoring and Long-Term Condition Coordination The post holder will help support the practice's recall and monitoring systems. Duties will include: • Supporting the implementation and ongoing use of Abtrace. • Helping the practice move from Ardens-based recall processes to Abtrace workflows. • Supporting recall processes for chronic disease reviews, medication monitoring and planned blood tests. • Monitoring recall lists and identifying patients who are overdue or have not responded. • Helping ensure appropriate appointment availability for recall and monitoring work. • Working with nursing, pharmacy and administrative teams to coordinate recall activity. • Supporting medication monitoring workflows, including shared care monitoring where appropriate. • Helping reduce duplicated or fragmented recall activity. • Supporting the development of SOPs and protocols for recall, non-responder management and escalation. • Identifying where recall processes are not working effectively and suggesting improvements. 3. Support for Vulnerable Patient Groups A key part of the role will be helping the practice identify patients who may need more proactive or personalised care. Duties will include: • Supporting improved coding and identification of housebound patients. • Supporting accurate coding and identification of care home residents. • Supporting improved identification and coding of carers. • Supporting coordination for patients with learning disabilities and other disabilities. • Identifying patients who may not respond to standard digital recall methods. • Helping develop workflows for patients who need additional contact, carer involvement or professional coordination. • Supporting the practice to target additional care, communication and compassion towards patients who are more vulnerable or less able to navigate standard systems. • Working within agreed protocols to ensure concerns are passed to the right clinician, team or external professional. 4. Digital Systems Coordination The post holder will provide practical coordination and oversight for digital systems used within the practice in relation to the coordination of care. Duties may include: • Developing a strong working knowledge of key practice systems including EMIS, Abtrace, AccuRx and BetterLetter. • Acting as a local point of contact for digital workflow queries within the practice. • Helping coordinate the practice response when key clinical or operational systems are disrupted, for example EMIS downtime, to ensure maintenance of patient care. • Supporting the development and maintenance of downtime processes and communication plans. • Liaising with external IT support, suppliers or system providers where appropriate. • Helping staff understand changes to digital systems and workflows in relation to care pathways. • Supporting training for practice staff when systems or processes change. • Helping create simple guides, SOPs and training materials. • Identifying recurring digital workflow problems and suggesting practical solutions. • Advising the Operations Lead and partners on digital system issues affecting patient care, safety, access or efficiency. • Helping ensure digital processes are safe, consistent and understood across the practice. 5. Digital Training and Practice Support The post holder will help improve confidence and consistency in the use of practice systems. Duties may include: • Supporting staff training on agreed digital workflows. • Helping new staff understand relevant digital systems. • Producing quick-reference guides or process notes. • Helping identify where staff need further training or support. • Supporting implementation of new systems or major workflow changes. • Helping ensure changes are communicated clearly to affected teams. • Working with leads and managers to ensure systems are used consistently. • Supporting learning from digital incidents, system outages or workflow failures. 6. Communication and Patient Engagement The post holder will support clear communication with patients and carers, particularly where this relates to recall, monitoring, vulnerable patient groups or access to care. Duties may include: • Supporting patient-facing communication about recall and monitoring processes. • Helping draft clear SMS, email, website or written messages. • Supporting communication campaigns linked to long-term condition reviews, medicines monitoring or patient access. • Helping ensure communication is accessible to patients and carers. • Supporting communication with care homes, carers and other professionals. • Identifying where communication processes are not working well and suggesting improvements. 7. Quality Improvement, Data and Reporting The post holder will support the practice in using data and digital systems to improve care. Duties may include: • Reviewing recall dashboards, reports and patient lists. • Identifying patterns in overdue monitoring, non-response or coding gaps. • Supporting audits linked to recall, medicines monitoring, patient cohorts or digital workflows. • Helping monitor whether recall systems are working as intended. • Supporting quality improvement projects linked to patient access, safety, coding or continuity. • Producing simple reports or summaries for managers and clinicians where required. • Helping identify practical improvements from day-to-day system use. 8. Team Working and Professional Boundaries The post holder will work closely with clinical, administrative and operational teams. Duties will include: • Working collaboratively with GPs, nurses, pharmacists, administrators and managers. • Supporting joined-up working between clinical and non-clinical teams. • Attending relevant meetings and training. • Working within agreed protocols and escalation routes. • Recognising the limits of the role and not giving clinical advice unless specifically trained and authorised. • Escalating clinical, safeguarding or operational concerns appropriately. • Maintaining confidentiality and information governance standards at all times. Training and Development The practice will support the successful candidate with: • Care Coordinator training in line with ARRS requirements. • Training in personalised care and care navigation principles. • System-specific training, including EMIS, Abtrace, AccuRx and BetterLetter. • Information governance and safeguarding training. • Support to develop skills in recall management and population health. • Support to develop skills in digital systems coordination and staff training. • Ongoing supervision from the Operations Lead, management team and clinical partners. The role is expected to evolve as the practice develops its recall, medicines monitoring, chronic disease management and digital systems.