Care Co-ordinator - HIPC PCN

Job description

Job responsibilities

Main Duties & Responsibilities

Frailty & Community Hub Co-ordination

Frailty Identification & Navigation:

Support the proactive identification and coding of moderately and severely frail patients. Serve as a central point of co-ordination between GP practices, the Community Frailty Hub, District Nurses, Community Therapy Teams, and Adult Social Care.

Personalised Care & Reablement Support: Assist in delivering person-centred care plans that encourage patient independence, goal engagement, and safe living within their own homes.

Physical Observations & Early Warning: Perform and accurately record basic physical observations (e.g., blood pressure, pulse oximetry, blood sugar) when indicated or instructed by a clinician. Monitor patients for subtle changes in condition and immediately escalate concerns to clinical staff.

Assessment & Visit Workflow: Facilitate first visit assessment documentation, maintain pre-visit summaries and ensure pre-visit data is accurately communicated across the MDT.

Signposting & Referral Pathways: Actively refer and signpost patients and carers to appropriate community services, voluntary agencies, and reablement programmes (e.g., home exercise plans set by therapy teams) to mitigate admission risks.

Cancer Care & Prevention

Co-ordinate contact with newly diagnosed cancer patients and monitor the 2 week wait referral process.

Proactively invite patients for screening (cervical, breast, bowel) and target non-responders to increase uptake.

Track necessary routine monitoring tests for cancer management and present learning/data at monthly governance meetings.

End of Life Care (EOLC) & Complex Needs

Assist in identifying and correctly coding palliative and complex patients.

Ensure regular annual and clinical reviews occur, assisting with correct DNAR record coding and reviews.

Liaise with social prescribing link workers, health/wellbeing coaches, and community providers to manage physical and psychological needs.

Learning Disabilities (LD) & Safeguarding

Support LD register patients with annual reviews, accessible communications, and uptake of preventative measures (flu/COVID jabs, screening).

Oversee safeguarding workflow, record management, document summarising, and coding across PCN practices, maintaining child/adult registers and liaising with MASH.

General Administrative & MDT Duties

Maintain accurate, timely electronic records (/EMIS Web) for all contact points, ensuring CQC documentation requirements are met.

Participate in vaccination call/recall campaigns and support practice reception/triage cover when required.

Contribute to safe service delivery through planned/unplanned cover and active involvement in team training and 1-to-1 performance reviews.

Person Specification

Experience

Essential

• Working in a patient-focused/community setting
• Multi-disciplinary team working & administrative systems
• Independent workload prioritization

Desirable

• Experience in Primary Care, PCNs, or Frailty Hubs
• Supporting service improvement or clinical audit

Skills & Competencies

Essential

• Excellent verbal & written communication
• IT literacy (EMIS Web, MS Office)
• Basic physical observation monitoring skills (or willingness to train)
• Ability to recognize boundaries and escalate clinical concerns promptly

Desirable

• Network building with external health and social care partners
• Ability to motivate patients in goal setting & rehabilitation

Behaviours / Attributes

Essential

• Compassionate, solution-focused, and patient-centred
• Commitment to equality, dignity, privacy, and confidentiality
• Adaptable team player with strong time management

Qualifications

Essential

• NVQ Level 3 or equivalent experience in health/social care
• Enhanced DBS with Adult/Child Barred List clearance

Desirable

• Care Certificate

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Employer details

Employer name

North Staffordshire GP Federation

Address

Holistic Person-Centred Care (HIPC) PCN

Tunstall and Surrounding Area

Stoke on Trent

ST6 6BE

United Kingdom

Employer's website

https://www.northstaffordshiregpfederation.nhs.uk