CLINICAL CARE COORDINATOR

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. Job description Job responsibilities 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.