Nurse (RGN) / Care Co-ordinator

Care Co-ordinator role: Patient identification and engagement. Support the identification of patients eligible for the Proactive Care contract using agreed criteria and patient lists. Proactively contact patients to explain the programme and encourage engagement. Build positive relationships with patients, carers, and families to understand their needs and goals. Ensure patients are supported to access appropriate services and interventions. Co-ordinate appointments and assessments with clinicians and members of the multidisciplinary team where required. Arrange and manage bookings for proactive care reviews and follow-up interventions. Support patients to navigate health, social care, and community services. Monitor patient progress and maintain regular contact where appropriate. Code as necessary in System One. Work closely with PCN teams, GP practices, neighbourhood teams, community healthcare providers, and social care service providers. Develop strong links with voluntary, community, and faith sector organisations to maximise support available to patients. Facilitate appropriate referrals and signposting to community-based services and wellbeing programmes. Promote integrated working and information sharing across organisations in line with governance requirements. Work with neighbourhood teams to ensure patients receive co-ordinated, high-quality care. Help identify and reduce duplication of services and interventions. Contribute to multidisciplinary team meetings and case discussions. Escalate concerns regarding patient wellbeing, safeguarding, or deterioration to the appropriate clinical professional. Administration and data management with support from other team members Maintain accurate and timely records on clinical systems and project databases. Support data collection and reporting requirements for the project. Ensure all contacts, referrals, and outcomes are appropriately documented. Assist with monitoring project activity and performance against agreed targets. RGN Nurse role: Clinical Assessment. Holistic patient assessments. Frailty assessments (including use of recognised frailty tools). Physical health assessments. Vital signs monitoring (BP, pulse, temperature, oxygen saturation, respiratory rate). NEWS2 scoring. Falls risk assessments. Pressure ulcer risk assessments. Nutritional assessments (e.g. MUST). Mental capacity assessments (within their competence). Continence assessments. End-of-life care assessments. Long-term condition reviews (where appropriately trained). Clinical Care. Wound care and dressings. Venepuncture (blood taking). Vaccinations and immunisations. ECG recording. Urinalysis. Specimen collection. Monitoring patients after hospital discharge. Basic respiratory assessments. Health promotion and lifestyle advice. Care Planning. Develop personalised care and support plans. Create anticipatory care plans. Coordinate advance care planning discussions. Review and update care plans. Support patients with self-management. Coordinate multidisciplinary team (MDT) meetings. Liaise with GPs, community nurses, therapists, pharmacists and social care. Refer patients to appropriate community services. Coordinate hospital discharge follow-up. Support admission avoidance initiatives where appropriate. Monitor patients identified as high risk. Ensure patients receive appropriate follow-up. Care Home Support. Complete routine care home resident reviews. Support proactive frailty rounds. Identify deteriorating residents early. Work alongside Frailty ANP Lead and pharmacy teams. Support care home staff with clinical advice. Help reduce avoidable hospital admissions. Discuss falls prevention. Encourage vaccination uptake. Support carers with disease management. Documentation. Maintain accurate clinical records. Document consultations in SystemOne (S1). Record clinical coding. Complete referrals and clinical correspondence. Quality Improvement. Participate in clinical audits. Support service improvement projects. Monitor quality indicators. Contribute to PCN and ICB targets. For a PCN Proactive Care role, an RGN is particularly well placed to: Carry out comprehensive frailty reviews. Visit housebound patients and care homes. Identify patients at risk of deterioration. Coordinate care across health and social care services. Deliver preventative interventions. Support anticipatory care planning. Help reduce avoidable hospital admissions and improve patient outcomes. This combination of clinical nursing skills and care coordination makes the role an excellent fit for delivering proactive, community-based care. The working week will be set as a rota with support from team around. Job description Job responsibilities Care Co-ordinator role: Patient identification and engagement. Support the identification of patients eligible for the Proactive Care contract using agreed criteria and patient lists. Proactively contact patients to explain the programme and encourage engagement. Build positive relationships with patients, carers, and families to understand their needs and goals. Ensure patients are supported to access appropriate services and interventions. Co-ordinate appointments and assessments with clinicians and members of the multidisciplinary team where required. Arrange and manage bookings for proactive care reviews and follow-up interventions. Support patients to navigate health, social care, and community services. Monitor patient progress and maintain regular contact where appropriate. Code as necessary in System One. Work closely with PCN teams, GP practices, neighbourhood teams, community healthcare providers, and social care service providers. Develop strong links with voluntary, community, and faith sector organisations to maximise support available to patients. Facilitate appropriate referrals and signposting to community-based services and wellbeing programmes. Promote integrated working and information sharing across organisations in line with governance requirements. Work with neighbourhood teams to ensure patients receive co-ordinated, high-quality care. Help identify and reduce duplication of services and interventions. Contribute to multidisciplinary team meetings and case discussions. Escalate concerns regarding patient wellbeing, safeguarding, or deterioration to the appropriate clinical professional. Administration and data management with support from other team members Maintain accurate and timely records on clinical systems and project databases. Support data collection and reporting requirements for the project. Ensure all contacts, referrals, and outcomes are appropriately documented. Assist with monitoring project activity and performance against agreed targets. RGN Nurse role: Clinical Assessment. Holistic patient assessments. Frailty assessments (including use of recognised frailty tools). Physical health assessments. Vital signs monitoring (BP, pulse, temperature, oxygen saturation, respiratory rate). NEWS2 scoring. Falls risk assessments. Pressure ulcer risk assessments. Nutritional assessments (e.g. MUST). Mental capacity assessments (within their competence). Continence assessments. End-of-life care assessments. Long-term condition reviews (where appropriately trained). Clinical Care. Wound care and dressings. Venepuncture (blood taking). Vaccinations and immunisations. ECG recording. Urinalysis. Specimen collection. Monitoring patients after hospital discharge. Basic respiratory assessments. Health promotion and lifestyle advice. Care Planning. Develop personalised care and support plans. Create anticipatory care plans. Coordinate advance care planning discussions. Review and update care plans. Support patients with self-management. Coordinate multidisciplinary team (MDT) meetings. Liaise with GPs, community nurses, therapists, pharmacists and social care. Refer patients to appropriate community services. Coordinate hospital discharge follow-up. Support admission avoidance initiatives where appropriate. Monitor patients identified as high risk. Ensure patients receive appropriate follow-up. Care Home Support. Complete routine care home resident reviews. Support proactive frailty rounds. Identify deteriorating residents early. Work alongside Frailty ANP Lead and pharmacy teams. Support care home staff with clinical advice. Help reduce avoidable hospital admissions. Discuss falls prevention. Encourage vaccination uptake. Support carers with disease management. Documentation. Maintain accurate clinical records. Document consultations in SystemOne (S1). Record clinical coding. Complete referrals and clinical correspondence. Quality Improvement. Participate in clinical audits. Support service improvement projects. Monitor quality indicators. Contribute to PCN and ICB targets. For a PCN Proactive Care role, an RGN is particularly well placed to: Carry out comprehensive frailty reviews. Visit housebound patients and care homes. Identify patients at risk of deterioration. Coordinate care across health and social care services. Deliver preventative interventions. Support anticipatory care planning. Help reduce avoidable hospital admissions and improve patient outcomes. This combination of clinical nursing skills and care coordination makes the role an excellent fit for delivering proactive, community-based care. The working week will be set as a rota with support from team around.