PAC Care Coordinator

The Proactive Anticipatory Care Neighbourhood Care Coordinator will support the delivery of personalised, proactive, and holistic care within the Primary Care Network (PCN), working as part of a multidisciplinary team (MDT). The post holder will coordinate care for a defined caseload of patients, ensuring timely communication, collaboration, and follow up across health, social care, and community services. Acting as a central point of contact for patients, families, and professionals, the Coordinator will facilitate effective anticipatory care planning, monitor outcomes, and promote continuity of care to improve health and wellbeing within the neighbourhood population.

Main duties of the job

To support the delivery of personalised, proactive, and holistic care within the Primary Care Network, working as part of a multidisciplinary team.

To be responsible for a caseload of patients aligned to a specific neighbourhood primary care team.

Ensure the right professionals are involved, notified and prepared for the meetings in advance.

Produce high quality notes following MDT meetings to include agreed and assigned actions.

Carry out home visits for assessment, monitoring, and delivery of care as appropriate.

Participate in the review of patient outcomes and goals over time.

Act as a central, continuous point of contact for the patient, their relatives/carers and the professionals involved in the care plan.

Collaborate with community teams, families, carers, and external partners to support coordinated care delivery.

Effectively signpost patients to appropriate health and wellbeing services best placed to meet unmet care needs.

Work collaboratively with the nursing team and social prescribing team within the PAC service and escalates patients who require more specialised input from those services when required.

Support the coordination and implementation of personalised care plans reflecting patient preferences, goals, and needs.

Refer or request referrals on patients' behalf to appropriate services that can assist with meeting outstanding care needs.

Job responsibilities

• Participate in weekly referral triage meetings to assist in identifying appropriate referrals.
• Work closely with the PAC MDT coordinators to ensure that GP/complex meetings are arranged, coordinated, and communicated, with all necessary information available in a timely manner.
• Ensure all records are comprehensive, complete, and available. Update patient records and universal care plan in a timely manner to ensure coordinators and other service providers have access to any patient updates/progress.
• Present yourself as an ambassador for the service and attend external practice/service meetings to promote the PAC MDT service when necessary.
• Attend relevant PAC service meetings as required.
• Ensure that all PAC service policies are fully adhered to.
• Participate in evaluating patient goals and outcomes to help guide ongoing care plans and support improvements within the service.
• Direct patients to suitable services and resources to support their empowerment and enable them to manage their own health.
• Must have a full, clean driving licence and access to a car for home visits.

Person Specification Qualifications

• Educated to GCSE level, including English and Mathematics at grade C or above or equivalent.
• Previous experience working in health or social care sector.
• Evidence of appropriate continuing professional development and education to maintain up to date knowledge.
• Previous experience working as a HCSW.
• Training in coaching, motivational interviewing, or care navigation.
• NVQ level 3 in a related field.

Experience

• Significant previous experience in project or team administration.
• Previous experience working within a busy team or project office.
• Supporting implementation of projects or new initiatives.
• Supporting the monitoring of information and evaluation of a new project or initiative.
• Previous work within the NHS, social care or voluntary and community sector.
• Previous work within multi disciplinary teams.

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.

Depending on experience, aligned with NHS Band 4.