HEALTH CARE CO-ORDINATOR

The Health Care Coordinator contributes to the delivery of the Primary Care Network (PCN) Direct Enhanced Service (DES), supporting proactive, personalised care and population health management for individuals with complex needs, frailty, long-term conditions, and those at risk of unplanned admission. The role supports the delivery of: • Enhanced Health in Care Homes EHCH service specification • Anticipatory care for high-risk cohorts • Personalised Care and Support Planning PCSP • Multidisciplinary team MDT working across primary, community, social care, and voluntary sectors This role supports reducing health inequalities through proactive case management, care coordination, and structured clinical support within HCA/Nurse Associate competency and delegation frameworks. The post holder works under the supervision of registered clinicians and is central to coordinating care across PCN multidisciplinary services, ensuring patients receive timely, coordinated, and person-centred care aligned to PCN DES and member practice requirements. Clinical Governance & Delegation The post holder undertakes delegated clinical activity in line with NHS England HCA/Nurse Associate competencies and PCN clinical governance arrangements, including: • Basic clinical observations and structured monitoring • Supporting long-term condition reviews under clinical protocols • Supporting vaccination delivery programmes under direction • Early identification of deterioration in frailty and LTC cohorts • Escalation of clinical concerns to registered clinicians in line with agreed pathways All clinical activity is undertaken within: • Local PCN SOPs • Clinical supervision arrangements • Professional competency frameworks HCA / Care Certificate level or above 2. Core Responsibilities PCN DES Aligned 2.1 MDT Coordination EHCH & Anticipatory Care Delivery In line with PCN DES requirements for MDT working, the post holder will: • Coordinate and schedule regular MDT meetings for EHCH and high-risk cohorts • Develop and maintain MDT case lists prioritised using risk stratification tools frailty, admission risk, care home residency, LTC complexity • Collate and present relevant patient information including: • Recent primary care interactions • Secondary care admissions and discharges • Community health input • Medication changes • Vaccination status and care gaps • Relevant clinical observations where recorded by HCA/Nurse Associate or community teams • Record MDT decisions, ensuring: • Clear allocation of actions • Named responsible professionals • Agreed timescales • Monitor completion of MDT actions and escalate delays or clinical risk to the PCN clinical lead 2.2 Personalised Care and Support Planning PCSP In line with NHSE PCN DES personalised care requirements, the post holder will: • Maintain and update Personalised Care and Support Plans PCSPs ensuring they are: • Person-centred and outcome-focused • Regularly reviewed following MDT discussions • Updated post-discharge or following change in condition PCSPs will include: • Clinical summary GP-led input • Functional, social, and wellbeing needs • What matters to me statements • Advance Care Planning ACP / Treatment Escalation Plans TEP • Risk stratification frailty, falls risk, admission risk • Preventative care status including immunisations • Relevant HCA-contributed observations and monitoring data where applicable 2.3 Enhanced Health in Care Homes EHCH & Preventative Care In alignment with EHCH DES requirements, the post holder will: • Maintain oversight of care home and housebound cohorts • Support proactive care planning for residents in care homes • Maintain vaccination registers for priority groups: • Flu • COVID-19 boosters • Pneumococcal • Shingles • RSV • Support vaccination programmes through: • Identification of eligible patients • Pre-vaccination screening and consent processes within competence • Coordination of vaccination delivery with PCN clinical teams and providers • Administration of vaccines within competency • Support outbreak prevention planning in care homes through timely data provision 2.4 Care Coordination and Navigation PCN DES Personalised Care Model The post holder will: • Act as a point of contact for patients requiring care co-ordination support • Support navigation across health, social care, and voluntary sector services • Facilitate access to: • Social prescribing link workers • Community and voluntary sector services • Rehabilitation and support services • Support patients and carers to understand: • PCSPs • Care pathways • Follow-up actions from MDTs • Escalate safeguarding or clinical concerns in line with PCN policies 2.5 Structured Clinical Support HCA/Nurse Associate Function within PCN DES Delivery In support of PCN anticipatory care and long-term condition management, the post holder will within competency: • Undertake and record baseline clinical observations, including: • Blood pressure • Pulse • Oxygen saturation • Temperature • Weight / BMI • Support long-term condition monitoring pathways, including: • Diabetes • Hypertension • COPD and asthma • Support identification of: • Clinical deterioration • Frailty escalation • Increased risk of admission • Escalate abnormal findings promptly to registered clinicians in accordance with PCN SOPs 2.6 Discharge and Transfer of Care Unplanned Admission Avoidance In line with PCN DES admission avoidance objectives, the post holder will: • Monitor discharge notifications from secondary care and community settings • Ensure follow-up actions are coordinated within 7 days of discharge • Support reconciliation of: • Medication changes (with pharmacy/clinical teams) • Care plans and PCSP updates • Clinical monitoring requirements • Liaise with: • Hospital discharge teams • Community services • Care homes • PCN clinical pharmacists and GPs 2.7 Population Health Management & Data Quality In alignment with PCN DES population health requirements, the post holder will: • Maintain accurate registers for: • Frailty cohort • Care home residents • Long-term conditions • Vaccination status • End-of-life ACP registers • Ensure accurate clinical coding in line with NHS standards: • Frailty e.g. Rockwood CFS • Care planning status • Immunisation records • TEP ACP documentation • Support PCN reporting requirements including: • EHCH service delivery metrics • Vaccination uptake • Admission avoidance indicators • PCN DES contractual reporting 4. Key Interfaces In line with PCN DES multidisciplinary working: PCN Core Team • GPs clinical leadership • PCN pharmacists • Social prescribing link workers • First contact practitioners AHPs • Mental health practitioners • Nursing and HCA workforce External Partners • Care homes EHCH framework • Community health services • Acute hospital discharge teams • Local authority social care • Voluntary and community sector organisations 5. Key Performance Indicators PCN DES Aligned Performance will be measured against PCN DES and EHCH outcomes: • Percentage of eligible patients with up-to-date PCSPs • Timeliness of MDT review and action completion • Vaccination uptake rates in priority cohorts • Timeliness of post-discharge follow-up within 7 days • Reduction in avoidable emergency admissions in frailty cohort • Coverage of care home residents within EHCH framework • Patient and carer experience of coordinated care 6. Competency and Training Requirements NHSE Aligned • HCA/Nurse Associate/Care Certificate or equivalent qualification • Competence in clinical observations and escalation protocols • Understanding of PCN DES, EHCH, and personalised care frameworks • Knowledge of frailty and population health management principles • Experience of MDT working in primary care or community settings • Data quality, coding, and clinical system literacy • Safeguarding adults and children level training • Understanding of vaccination programmes and eligibility criteria • Ability to work within clinical governance and delegated responsibility frameworks • Flexibility Clause The duties of this role may evolve in line with PCN priorities, ARRS guidance, QOF, and DES requirements. Governance Statement This role operates within the PCN DES contractual framework and NHSE clinical governance requirements. This job description may is not exhaustive and may change in line with organisational contractual and service delivery requirements. All clinical activity is undertaken under appropriate delegation, supervision, and competency assurance. The post holder is required to escalate any clinical concerns outside their scope of practice in line with PCN escalation policies. Job description Job responsibilities The Health Care Coordinator contributes to the delivery of the Primary Care Network (PCN) Direct Enhanced Service (DES), supporting proactive, personalised care and population health management for individuals with complex needs, frailty, long-term conditions, and those at risk of unplanned admission. The role supports the delivery of: • Enhanced Health in Care Homes EHCH service specification • Anticipatory care for high-risk cohorts • Personalised Care and Support Planning PCSP • Multidisciplinary team MDT working across primary, community, social care, and voluntary sectors This role supports reducing health inequalities through proactive case management, care coordination, and structured clinical support within HCA/Nurse Associate competency and delegation frameworks. The post holder works under the supervision of registered clinicians and is central to coordinating care across PCN multidisciplinary services, ensuring patients receive timely, coordinated, and person-centred care aligned to PCN DES and member practice requirements. Clinical Governance & Delegation The post holder undertakes delegated clinical activity in line with NHS England HCA/Nurse Associate competencies and PCN clinical governance arrangements, including: • Basic clinical observations and structured monitoring • Supporting long-term condition reviews under clinical protocols • Supporting vaccination delivery programmes under direction • Early identification of deterioration in frailty and LTC cohorts • Escalation of clinical concerns to registered clinicians in line with agreed pathways All clinical activity is undertaken within: • Local PCN SOPs • Clinical supervision arrangements • Professional competency frameworks HCA / Care Certificate level or above 2. Core Responsibilities PCN DES Aligned 2.1 MDT Coordination EHCH & Anticipatory Care Delivery In line with PCN DES requirements for MDT working, the post holder will: • Coordinate and schedule regular MDT meetings for EHCH and high-risk cohorts • Develop and maintain MDT case lists prioritised using risk stratification tools frailty, admission risk, care home residency, LTC complexity • Collate and present relevant patient information including: • Recent primary care interactions • Secondary care admissions and discharges • Community health input • Medication changes • Vaccination status and care gaps • Relevant clinical observations where recorded by HCA/Nurse Associate or community teams • Record MDT decisions, ensuring: • Clear allocation of actions • Named responsible professionals • Agreed timescales • Monitor completion of MDT actions and escalate delays or clinical risk to the PCN clinical lead 2.2 Personalised Care and Support Planning PCSP In line with NHSE PCN DES personalised care requirements, the post holder will: • Maintain and update Personalised Care and Support Plans PCSPs ensuring they are: • Person-centred and outcome-focused • Regularly reviewed following MDT discussions • Updated post-discharge or following change in condition PCSPs will include: • Clinical summary GP-led input • Functional, social, and wellbeing needs • What matters to me statements • Advance Care Planning ACP / Treatment Escalation Plans TEP • Risk stratification frailty, falls risk, admission risk • Preventative care status including immunisations • Relevant HCA-contributed observations and monitoring data where applicable 2.3 Enhanced Health in Care Homes EHCH & Preventative Care In alignment with EHCH DES requirements, the post holder will: • Maintain oversight of care home and housebound cohorts • Support proactive care planning for residents in care homes • Maintain vaccination registers for priority groups: • Flu • COVID-19 boosters • Pneumococcal • Shingles • RSV • Support vaccination programmes through: • Identification of eligible patients • Pre-vaccination screening and consent processes within competence • Coordination of vaccination delivery with PCN clinical teams and providers • Administration of vaccines within competency • Support outbreak prevention planning in care homes through timely data provision 2.4 Care Coordination and Navigation PCN DES Personalised Care Model The post holder will: • Act as a point of contact for patients requiring care co-ordination support • Support navigation across health, social care, and voluntary sector services • Facilitate access to: • Social prescribing link workers • Community and voluntary sector services • Rehabilitation and support services • Support patients and carers to understand: • PCSPs • Care pathways • Follow-up actions from MDTs • Escalate safeguarding or clinical concerns in line with PCN policies 2.5 Structured Clinical Support HCA/Nurse Associate Function within PCN DES Delivery In support of PCN anticipatory care and long-term condition management, the post holder will within competency: • Undertake and record baseline clinical observations, including: • Blood pressure • Pulse • Oxygen saturation • Temperature • Weight / BMI • Support long-term condition monitoring pathways, including: • Diabetes • Hypertension • COPD and asthma • Support identification of: • Clinical deterioration • Frailty escalation • Increased risk of admission • Escalate abnormal findings promptly to registered clinicians in accordance with PCN SOPs 2.6 Discharge and Transfer of Care Unplanned Admission Avoidance In line with PCN DES admission avoidance objectives, the post holder will: • Monitor discharge notifications from secondary care and community settings • Ensure follow-up actions are coordinated within 7 days of discharge • Support reconciliation of: • Medication changes (with pharmacy/clinical teams) • Care plans and PCSP updates • Clinical monitoring requirements • Liaise with: • Hospital discharge teams • Community services • Care homes • PCN clinical pharmacists and GPs 2.7 Population Health Management & Data Quality In alignment with PCN DES population health requirements, the post holder will: • Maintain accurate registers for: • Frailty cohort • Care home residents • Long-term conditions • Vaccination status • End-of-life ACP registers • Ensure accurate clinical coding in line with NHS standards: • Frailty e.g. Rockwood CFS • Care planning status • Immunisation records • TEP ACP documentation • Support PCN reporting requirements including: • EHCH service delivery metrics • Vaccination uptake • Admission avoidance indicators • PCN DES contractual reporting 4. Key Interfaces In line with PCN DES multidisciplinary working: PCN Core Team • GPs clinical leadership • PCN pharmacists • Social prescribing link workers • First contact practitioners AHPs • Mental health practitioners • Nursing and HCA workforce External Partners • Care homes EHCH framework • Community health services • Acute hospital discharge teams • Local authority social care • Voluntary and community sector organisations 5. Key Performance Indicators PCN DES Aligned Performance will be measured against PCN DES and EHCH outcomes: • Percentage of eligible patients with up-to-date PCSPs • Timeliness of MDT review and action completion • Vaccination uptake rates in priority cohorts • Timeliness of post-discharge follow-up within 7 days • Reduction in avoidable emergency admissions in frailty cohort • Coverage of care home residents within EHCH framework • Patient and carer experience of coordinated care 6. Competency and Training Requirements NHSE Aligned • HCA/Nurse Associate/Care Certificate or equivalent qualification • Competence in clinical observations and escalation protocols • Understanding of PCN DES, EHCH, and personalised care frameworks • Knowledge of frailty and population health management principles • Experience of MDT working in primary care or community settings • Data quality, coding, and clinical system literacy • Safeguarding adults and children level training • Understanding of vaccination programmes and eligibility criteria • Ability to work within clinical governance and delegated responsibility frameworks • Flexibility Clause The duties of this role may evolve in line with PCN priorities, ARRS guidance, QOF, and DES requirements. Governance Statement This role operates within the PCN DES contractual framework and NHSE clinical governance requirements. This job description may is not exhaustive and may change in line with organisational contractual and service delivery requirements. All clinical activity is undertaken under appropriate delegation, supervision, and competency assurance. The post holder is required to escalate any clinical concerns outside their scope of practice in line with PCN escalation policies.