About this role
Job summary
Bradford City 5 Primary Care Network is looking for an enthusiastic, organised and compassionate Care Co-ordinator to join our growing PCN team.
This is an exciting opportunity to make a real difference to patients across our eight GP practices in inner-city Bradford. You will work closely with patients, carers, GP practices and our wider multidisciplinary team to help people navigate health and care services, understand the next steps in their care and access the support they need.
You will support patients with a range of needs, including people living with long-term conditions, frailty or dementia and those who may experience barriers to accessing healthcare. You will manage an agreed caseload, coordinate appointments and referrals, support multidisciplinary team working and make sure agreed actions are followed through.
You will join an established PCN team including Social Prescribing Link Workers, Health and Wellbeing Coaches, Clinical Pharmacists and other healthcare professionals.
We are looking for someone with excellent communication and organisational skills who is passionate about personalised care, reducing health inequalities and improving patients' experience of healthcare.
Main duties of the job
The Care Co-ordinator will work across Bradford City 5 PCN, supporting patients to navigate health, care and community services and ensuring that agreed actions are followed through.
The postholder will manage an agreed caseload of patients and work closely with GP practices and the wider multidisciplinary team. Key duties will include contacting patients and carers, coordinating appointments, referrals and reviews, helping patients prepare for care conversations and addressing practical barriers that may prevent them from accessing support.
The role will support multidisciplinary team (MDT) working by preparing relevant information, recording agreed actions, identifying responsible professionals and tracking actions through to completion.
The Care Co-ordinator will maintain accurate and timely patient records using SystmOne and agreed PCN templates, and will support the PCN to monitor activity and outcomes.
The postholder will work particularly with patients who have complex needs, long-term conditions, frailty or dementia, and people who may experience health inequalities or barriers to accessing services.
This is a non-clinical role. The postholder will work within agreed boundaries and promptly escalate clinical, safeguarding or safety concerns to the appropriate professional.
About us
Bradford City 5 Primary Care Network (PCN) is a collaborative network of eight GP practices working together to improve health outcomes and provide high-quality, coordinated care for our diverse communities across inner-city Bradford.
Our member practices are Avicenna Medical Practice, Bevan Healthcare, Bradford Moor Practice, Dr Hamdani's Practice, Moor Park Medical Practice, Peel Park Surgery, Primrose Surgery and Valley View Surgery.
We have a growing multidisciplinary PCN team which includes Social Prescribing Link Workers, Health and Wellbeing Coaches, Clinical Pharmacists, Mental Health Practitioners, First Contact Physiotherapists and other professionals working alongside our GP practices.
Our communities experience significant health inequalities, and a key priority for our PCN is making services easier to access and ensuring that patients receive the right support at the right time.
We value collaborative working, new ideas and continuous improvement. The successful candidate will be supported by the PCN management team, receive appropriate induction, training and regular supervision, and have the opportunity to help shape and develop the Care Co-ordinator role as our services continue to evolve.
This is an opportunity to join a supportive PCN team and contribute directly to improving patient experience, personalised care and joined-up working across our practices.
Job description Job responsibilities
Job purpose
The PCN Care Co-ordinator will provide practical personalised support to patients whose care involves several professionals or services
The postholder will help patients understand the next steps in their care communicate what matters to them and access the support agreed with their clinical team
The postholder will maintain a defined caseload coordinate appointments and referrals follow multidisciplinary team actions through to an outcome and raise concerns promptly
The Care Co-ordinator will work across Bradford City Five PCN member practices and with the wider PCN multidisciplinary team
Patient care and co-ordination
Use clinician-approved patient lists practice referrals and multidisciplinary team recommendations to identify and engage patients requiring care co-ordination
Contact patients using agreed methods explain the service and identify their priorities communication needs and any barriers to accessing care
Maintain an accurate and current caseload including contact dates next actions responsible professionals review dates and outcomes
Help patients prepare for conversations with GPs nurses pharmacists and other healthcare professionals
Support patients to understand agreed actions and personalised care and support plans ensuring they know who is responsible for each action and what happens next
Arrange and track agreed appointments referrals and reviews and help resolve practical barriers that may prevent patients from accessing care
Follow up missed appointments and contacts in accordance with agreed PCN and practice procedures
Support access to appropriate self-management wellbeing and community services working closely with the PCN Social Prescribing and Health and Wellbeing teams
Supporting priority patient groups
The postholder will support agreed PCN patient cohorts which may include people with long-term conditions and complex needs
This will include supporting patients living with frailty or dementia and their carers to prepare for reviews and ensuring agreed actions are followed up
The Care Co-ordinator may also support patients experiencing repeated urgent-care use recent transitions of care difficulties attending appointments or other barriers to accessing healthcare
The postholder will support agreed screening vaccination and annual-review activity for patients within their caseload where appropriate
Multidisciplinary team working
Support the organisation and co-ordination of relevant patient multidisciplinary team discussions
Ensure appropriate information is available to support multidisciplinary team discussions through approved secure processes
Where possible establish the patient's priorities before their case is discussed
Accurately record agreed actions including the responsible professional and expected completion date
Track outstanding actions and escalate overdue or rejected referrals appropriately
Keep patients appropriately informed about agreed actions and follow-up
Work collaboratively with GPs nurses practice teams Social Prescribing Link Workers Health and Wellbeing Coaches Clinical Pharmacists mental health professionals physiotherapists and relevant community and voluntary-sector services
Record keeping and information governance
Document patient contacts and actions promptly and accurately in SystmOne using agreed PCN and practice templates and codes
Maintain confidentiality and comply with PCN and practice information governance data protection and information-sharing requirements
Use authorised systems and accounts and only access or share information necessary for the role
Verify identity and appropriate carer authority before sharing confidential patient information
Provide appropriate anonymised or aggregated activity and outcome information to support PCN monitoring and service development
Safety safeguarding and role boundaries
This is a non-clinical role
The Care Co-ordinator will not diagnose conditions independently assess clinical urgency prescribe medication interpret test results or make changes to a patient's treatment
Promptly escalate new symptoms deterioration medication concerns or other clinical concerns to an appropriate clinician
Recognise and respond appropriately to safeguarding concerns following local safeguarding procedures
Use urgent or emergency escalation routes where required in accordance with local procedures
Maintain clear factual records of concerns and actions taken
Work within their level of competence and seek advice or supervision whenever a task or situation falls outside their role
Follow relevant health and safety infection prevention equality accessibility incident reporting and lone-working procedures
Working with our communities
The postholder will work respectfully and sensitively with Bradford's diverse communities
They will identify patients' preferred language communication method accessibility requirements and safe contact arrangements
The postholder will use professional interpreting services through agreed routes where required
The Care Co-ordinator will recognise that some patients may experience digital exclusion or other barriers to accessing healthcare and will support appropriate alternative methods of communication and access
Training and development
Complete an appropriate induction programme and all required mandatory training
Undertake or complete the appropriate Care Co-ordination training pathway
Participate in regular supervision appraisal and continuing professional development
Maintain an appropriate learning and development record
Attend relevant PCN practice and multidisciplinary meetings
Identify opportunities to improve patient pathways and reduce barriers to accessing care
Contribute to patient and practice feedback and service improvement
Service development
The postholder will help colleagues understand the Care Co-ordination referral pathway and appropriate use of the service
They will contribute to the development of safe and effective processes for managing referrals caseloads multidisciplinary team actions follow-up and handover arrangements
The role will continue to develop in response to the needs of patients and the PCN
Any additional duties will be reasonable and consistent with the purpose level training and responsibilities of the Care Co-ordinator role
Management and accountability
The postholder will report to the PCN Manager and work within the governance arrangements of Bradford City Five PCN Limited
The postholder will receive named Care Co-ordination supervision and have access to appropriate clinical support and escalation routes
The role will work across the Bradford City Five PCN member practices and agreed community settings
Person Specification
Qualifications Essential
Relevant Level Three qualification or equivalent skills and experience Willingness and ability to undertake and complete the appropriate Care Co-ordination training pathway. Experience of supporting patients service users or carers within healthcare social care or a community setting Experience of coordinating appointments referrals or multi-step work and following actions through to completion Experience of maintaining accurate records and managing confidential or sensitive information Experience of organising and prioritising a workload and working with different professionals or services
Desirable
Experience of working within general practice a Primary Care Network or the NHS Experience of using SystmOne or another electronic patient record or case management system Experience of supporting people with frailty dementia long-term conditions or inclusion health needs Experience of supporting multidisciplinary team working personalised care plans or service improvement
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 The Bradford Moor Practice
Address Barkerend Health Centre
Barkerend Rd
Bradford
West Yorkshire
BD3 8QH
United Kingdom
Employer's website https://bradfordmoorpractice.co.uk/ (Opens in a new tab)