Taunton Central Primary Care Network
Care Coordinator for Enhanced Health in Care Homes
Taunton Central Primary Care Network, Taunton, Massachusetts, us, 02780
Care Coordinator for Enhanced Health in Care Homes
The CareCoordinator will be part of the Primary Care Network (PCN) which is responsiblefor managing the care of people registered with practices in the PCN. A keypart of the role of a care coordinator is in the Care Homes Multi-DisciplinaryTeam (MDT), improving the continuity of care by acting as a point of contactfor residents, families and professionals who visit care homes. This willinvolve coordinating the work of healthcare professionals and non-clinicalstaff including volunteers and third sector agencies involved in the care ofregistered patients. Main duties of the job
They willsupport the MDT with the weekly ward/home rounds, collating information onpeople requiring an MDT review and providing coordination and administrativesupport to the MDTs for their PCN(s). In thispatient facing role the post holder will also be responsible for a caseload ofpatients identified through the MDT meetings. Support provided directly withpatients and their carers would include co-producing personalised plans,utilising decision aids, providing information and training opportunities,making appointments, coordination and navigation for people and their carersacross health and care services. The postholder will contribute to tackling inequalities in health and social careparticularly regarding individuals with long-term conditions. An ethos ofpromotion of independence and partnership-working is integral to this post. About us
Taunton Central Primary Care Network has approximately 60,000 patients registered with four practices in Taunton and one practice in the neighbouring village of Bishops Lydeard. Working collaboratively to develop the best patient-centred care and services. We pride ourselves on our ability and willingness to adopt innovative ways of working that improve patient care and make our PCN a rewarding place to work. The five practices within Taunton Central PCN are: College Way Surgery, Crown Medical Centre, French Weir Health Centre, St James Medical Centre, and Quantock Vale Surgery. Travel across all five practices and sites is a requirement for this role. Job responsibilities
Accountable to: PCN Clinical Lead and PCN Business Manager Salary: £13.50-14.50 per hour (dependent on experience) Working hours: 30-34 hours per week Interviews: expected to take place week commencing 24 November 2025 at College Way Surgery Job Summary The CareCoordinator will be part of the Primary Care Network (PCN) which is responsiblefor managing the care of people registered with practices in the PCN. A keypart of the role of a care coordinator is in the Care Homes Multi-DisciplinaryTeam (MDT), improving the continuity of care by acting as a point of contactfor residents, families and professionals who visit care homes. This willinvolve coordinating the work of healthcare professionals and non-clinicalstaff including volunteers and third sector agencies involved in the care ofregistered patients. In thispatient facing role the post holder will also be responsible for a caseload ofpatients identified through the MDT meetings. Support provided directly withpatients and their carers would include co-producing personalised plans,utilising decision aids, providing information and training opportunities,making appointments, coordination and navigation for people and their carersacross health and care services. The postholder will contribute to tackling inequalities in health and social careparticularly regarding individuals with long-term conditions. An ethos ofpromotion of independence and partnership-working is integral to this post. Primary duties and areas of responsibility: Totake part in arranging the weekly PCN led MDT meetings (including the weeklyward/home rounds) and the smooth running of integrated care within the teamsetting. A key role of the Care Coordinator will be to schedule the weekly MDTmeetings, manage the meeting agenda items, ensuring that all new referrals areidentified, and information circulated to team members in advance of themeeting. Takeminutes of MDT meetings and disseminate, chase progress against actionsidentified in these meetings and ensure follow up where necessary. Manage acaseload of patients identified through the MDT. Supportpatients to utilise decision aids in preparation for a shared decision-makingconversation. Holisticallybring together all of a persons identified care and support needs and exploreoptions to meet these within a single personalised care and support plan(PCSP), in line with PCSP best practice, based on what matters to the person. Helppeople to manage their needs through answering queries, making and managingappointments, and ensuring that people have good quality written or verbalinformation to help them make choices about their care. Identifythe training needs of care home staff and escalate to the care home team orrelevant professional appropriately. Utilisepopulation health intelligence, which may include AI and related tools, toproactively identify and work with a cohort of patients to deliver personalisedcare. Receiveand collate information from transfers of care (including hospital admissionsand discharges) plus out of hours calls and present this information to the MDTas required. Liaisewith service providers and clinicians to identify high service users, and newservice users utilising risk stratification tools provided and present thisinformation to the weekly MDT meetings. Supportthe completion of new referrals by checking criteria, and where criteria havebeen met, direct referral to the MDT. Signpostteam members, service users and carers to relevant services. Liaisewith other stakeholders as needed for the collective benefit of patientsincluding but not limited to Patients GP, Nurses, other practice staff andotherhealthcare professionals including pharmacists and pharmacy technicians fromprovider and commissioning organisations. Act as apoint of contact for residents, families, carers and professionals who visitthe care home, such as MDT members and in-reach specialists. Meetregularly with the clinical lead and review case load and MDT function. Communicateeffectively with service users and their families/carers and providecoordination across health and care services working closely with socialprescribing link workers, health and wellbeing coaches, and other primary careprofessionals. Manageand prioritise workload on a daily basis and deal with the competing demands ofthe MDT. Act atall times in an anti-discriminatory manner. Undertakeany training required in order to maintain competency including mandatorytraining. Communicateeffectively and sensitively and use language appropriate to a patient andcarer/relatives condition and level of understanding. Be thepoint of liaison for service users and interface with all health and socialcare professionals, including keeping everyone informed and updated. Thepost holder will be required to work within clearly defined organisationalprotocols, policies and procedures. Thepost-holder must comply at all times with the PCN member practice Health andSafety policies, in particular by following agreed safe working procedures andreporting incidents using the practice Incident Reporting System. Thepost-holder will comply with the Data Protection Act (1984), The General DataProtection Regulations (2018) and the Access to Health Records Act (1990). Thepost-holder must co-operate with all policies and procedures designed to ensureequality of employment. Co-workers, patients and visitors must be treatedequally irrespective of gender, ethnic origin, age, disability, sexualorientation, religion etc. Thepost-holder should always respect patient confidentiality and not divulgepatient information unless sanctioned by the requirements of the role. Thepost-holder is required to travel independently between practice sites and toattend meetings etc. hosted by other agencies. The post holder must have access to a car as travel between sites across the Taunton area will be required. Job Description Agreement The job description is intended as a basic guide to the scope and responsibilities of the post and its not exhaustive. It will be subject to regular review and amendment as necessary in consultation with the post holder. Applications will be reviewed upon receipt; the advert may close early should a suitable candidate be identified. Person Specification
Qualifications
NVQ Level 2 or equivalent. Willing to work towards NVQ Level 3. Experience
Minimum of 2 years in health or social care profession. Understanding of primary care. Experience of working in a multidisciplinary setting. Demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality. Experience of administrative duties. Knowledge of the EHCH framework. Knowledge/familiarity with medical terminology. Understanding of current issues facing the NHS. Understanding of health and social care processes. Experience in use of databases. Experience of working in care homes. Knowledge of Primary Care. 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.
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The CareCoordinator will be part of the Primary Care Network (PCN) which is responsiblefor managing the care of people registered with practices in the PCN. A keypart of the role of a care coordinator is in the Care Homes Multi-DisciplinaryTeam (MDT), improving the continuity of care by acting as a point of contactfor residents, families and professionals who visit care homes. This willinvolve coordinating the work of healthcare professionals and non-clinicalstaff including volunteers and third sector agencies involved in the care ofregistered patients. Main duties of the job
They willsupport the MDT with the weekly ward/home rounds, collating information onpeople requiring an MDT review and providing coordination and administrativesupport to the MDTs for their PCN(s). In thispatient facing role the post holder will also be responsible for a caseload ofpatients identified through the MDT meetings. Support provided directly withpatients and their carers would include co-producing personalised plans,utilising decision aids, providing information and training opportunities,making appointments, coordination and navigation for people and their carersacross health and care services. The postholder will contribute to tackling inequalities in health and social careparticularly regarding individuals with long-term conditions. An ethos ofpromotion of independence and partnership-working is integral to this post. About us
Taunton Central Primary Care Network has approximately 60,000 patients registered with four practices in Taunton and one practice in the neighbouring village of Bishops Lydeard. Working collaboratively to develop the best patient-centred care and services. We pride ourselves on our ability and willingness to adopt innovative ways of working that improve patient care and make our PCN a rewarding place to work. The five practices within Taunton Central PCN are: College Way Surgery, Crown Medical Centre, French Weir Health Centre, St James Medical Centre, and Quantock Vale Surgery. Travel across all five practices and sites is a requirement for this role. Job responsibilities
Accountable to: PCN Clinical Lead and PCN Business Manager Salary: £13.50-14.50 per hour (dependent on experience) Working hours: 30-34 hours per week Interviews: expected to take place week commencing 24 November 2025 at College Way Surgery Job Summary The CareCoordinator will be part of the Primary Care Network (PCN) which is responsiblefor managing the care of people registered with practices in the PCN. A keypart of the role of a care coordinator is in the Care Homes Multi-DisciplinaryTeam (MDT), improving the continuity of care by acting as a point of contactfor residents, families and professionals who visit care homes. This willinvolve coordinating the work of healthcare professionals and non-clinicalstaff including volunteers and third sector agencies involved in the care ofregistered patients. In thispatient facing role the post holder will also be responsible for a caseload ofpatients identified through the MDT meetings. Support provided directly withpatients and their carers would include co-producing personalised plans,utilising decision aids, providing information and training opportunities,making appointments, coordination and navigation for people and their carersacross health and care services. The postholder will contribute to tackling inequalities in health and social careparticularly regarding individuals with long-term conditions. An ethos ofpromotion of independence and partnership-working is integral to this post. Primary duties and areas of responsibility: Totake part in arranging the weekly PCN led MDT meetings (including the weeklyward/home rounds) and the smooth running of integrated care within the teamsetting. A key role of the Care Coordinator will be to schedule the weekly MDTmeetings, manage the meeting agenda items, ensuring that all new referrals areidentified, and information circulated to team members in advance of themeeting. Takeminutes of MDT meetings and disseminate, chase progress against actionsidentified in these meetings and ensure follow up where necessary. Manage acaseload of patients identified through the MDT. Supportpatients to utilise decision aids in preparation for a shared decision-makingconversation. Holisticallybring together all of a persons identified care and support needs and exploreoptions to meet these within a single personalised care and support plan(PCSP), in line with PCSP best practice, based on what matters to the person. Helppeople to manage their needs through answering queries, making and managingappointments, and ensuring that people have good quality written or verbalinformation to help them make choices about their care. Identifythe training needs of care home staff and escalate to the care home team orrelevant professional appropriately. Utilisepopulation health intelligence, which may include AI and related tools, toproactively identify and work with a cohort of patients to deliver personalisedcare. Receiveand collate information from transfers of care (including hospital admissionsand discharges) plus out of hours calls and present this information to the MDTas required. Liaisewith service providers and clinicians to identify high service users, and newservice users utilising risk stratification tools provided and present thisinformation to the weekly MDT meetings. Supportthe completion of new referrals by checking criteria, and where criteria havebeen met, direct referral to the MDT. Signpostteam members, service users and carers to relevant services. Liaisewith other stakeholders as needed for the collective benefit of patientsincluding but not limited to Patients GP, Nurses, other practice staff andotherhealthcare professionals including pharmacists and pharmacy technicians fromprovider and commissioning organisations. Act as apoint of contact for residents, families, carers and professionals who visitthe care home, such as MDT members and in-reach specialists. Meetregularly with the clinical lead and review case load and MDT function. Communicateeffectively with service users and their families/carers and providecoordination across health and care services working closely with socialprescribing link workers, health and wellbeing coaches, and other primary careprofessionals. Manageand prioritise workload on a daily basis and deal with the competing demands ofthe MDT. Act atall times in an anti-discriminatory manner. Undertakeany training required in order to maintain competency including mandatorytraining. Communicateeffectively and sensitively and use language appropriate to a patient andcarer/relatives condition and level of understanding. Be thepoint of liaison for service users and interface with all health and socialcare professionals, including keeping everyone informed and updated. Thepost holder will be required to work within clearly defined organisationalprotocols, policies and procedures. Thepost-holder must comply at all times with the PCN member practice Health andSafety policies, in particular by following agreed safe working procedures andreporting incidents using the practice Incident Reporting System. Thepost-holder will comply with the Data Protection Act (1984), The General DataProtection Regulations (2018) and the Access to Health Records Act (1990). Thepost-holder must co-operate with all policies and procedures designed to ensureequality of employment. Co-workers, patients and visitors must be treatedequally irrespective of gender, ethnic origin, age, disability, sexualorientation, religion etc. Thepost-holder should always respect patient confidentiality and not divulgepatient information unless sanctioned by the requirements of the role. Thepost-holder is required to travel independently between practice sites and toattend meetings etc. hosted by other agencies. The post holder must have access to a car as travel between sites across the Taunton area will be required. Job Description Agreement The job description is intended as a basic guide to the scope and responsibilities of the post and its not exhaustive. It will be subject to regular review and amendment as necessary in consultation with the post holder. Applications will be reviewed upon receipt; the advert may close early should a suitable candidate be identified. Person Specification
Qualifications
NVQ Level 2 or equivalent. Willing to work towards NVQ Level 3. Experience
Minimum of 2 years in health or social care profession. Understanding of primary care. Experience of working in a multidisciplinary setting. Demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality. Experience of administrative duties. Knowledge of the EHCH framework. Knowledge/familiarity with medical terminology. Understanding of current issues facing the NHS. Understanding of health and social care processes. Experience in use of databases. Experience of working in care homes. Knowledge of Primary Care. 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.
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