About this role
Job summary
Havering Liberty Primary Care Network is seeking an organised, compassionate and proactive Care Coordinator to support patients living with long-term conditions. Working across our PCN practices, you will coordinate MDT meetings, manage patient call and recall processes, maintain accurate EMIS records and help patients access timely reviews, personalised care planning and wider community support. This is an excellent opportunity for someone with strong communication, IT and organisational skills who is passionate about improving patient outcomes and reducing health inequalities.
Main duties of the job
The LTC Proactive Care Coordinator will support delivery of the NEL Long Term Conditions (LTC) Proactive Care Quality and Outcomes Framework. The post holder will coordinate proactive care activities for identified patient cohorts, facilitate multidisciplinary team (MDT) meetings, undertake call and recall processes, maintain accurate clinical records using EMIS, and support achievement of the LTC Local Incentive Scheme (LIS) requirements and outcomes.
The role will ensure patients receive timely reviews, personalised care planning and coordinated support, contributing to improved health outcomes, reduced health inequalities and enhanced patient experience.
Key Duties and Responsibilities include:
MDT CoordinationCall and Recall ProcessesEMIS administration and data qualityCare planning supportPerformance and reportng
About us
Havering Liberty Primary Care Network
We are a collaborative neighbourhood healthcare network made up of five GP practices and an extended multidisciplinary team. Together, we provide accessible, patient-centred, high-quality primary care that supports the health and wellbeing of both our community and our workforce.
The PCN delivers a range of innovative initiatives to improve community health and wellbeing, including Social Prescribing projects that support high-intensity users, carers and bereaved families.
Our housebound frailty service is a particular success, having received Highly Commended awards and wider recognition for its effective support for frail, housebound patients.
The Leadership Team of Havering Liberty PCN is led by the Clinical Director. This team includes the Strategy and Transformation Manager and the PCN Operations Manager and Digital Facilitator working in collaboration with Leads for each practice within the PCN.
The PCN receives employment onboarding support from our lead practice Hornchurch Healthcare.
Job description Job responsibilities
The LTC Proactive Care Coordinator will support delivery of the NEL Long Term Conditions (LTC) Proactive Care Quality and Outcomes Framework. The post holder will coordinate proactive care activities for identified patient cohorts, facilitate multidisciplinary team (MDT) meetings, undertake call and recall processes, maintain accurate clinical records using EMIS, and support achievement of the LTC Local Incentive Scheme (LIS) requirements and outcomes.
The role will ensure patients receive timely reviews, personalised care planning and coordinated support, contributing to improved health outcomes, reduced health inequalities and enhanced patient experience.
Key Duties and Responsibilities include:
MDT Coordination
Organise and coordinate regular LTC MDT meetings at practice, PCN or neighbourhood level. Prepare patient lists and case summaries for discussion. Record actions, outcomes and agreed care plans from MDT meetings. Track completion of MDT actions and follow up with relevant clinicians and services. Liaise with community, mental health, social care, voluntary sector and secondary care partners as required. Ensure MDT discussions support personalised and holistic care planning. Call and Recall Processes
Identify eligible patients for LTC reviews using approved searches and cohort criteria. Operate systematic call and recall processes for annual reviews, care planning appointments and follow-up interventions. Contact patients via telephone, SMS, letters and other approved communication channels. Monitor uptake and non-attendance and take appropriate follow-up action. Maintain accurate records of invitations, appointments and outcomes. EMIS Administration and Data Quality
Maintain and update patient records using EMIS. Apply agreed LTC templates and care planning tools. Ensure appropriate clinical coding and recording of care plan activity, wider determinants of health, personalised care discussions and MDT outcomes. Support data quality improvement by identifying coding gaps and outstanding actions. Run EMIS searches and reports to support performance monitoring and service delivery. Ensure information is recorded in accordance with PCN, ICB and information governance requirements Care Planning Support
Support delivery of the Year of Care approach. Assist patients to access appropriate services, including social prescribing, community services and self-management support. Ensure care plans reflect patient goals, preferences and identified needs. Support identification and recording of wider determinants of health. Performance and Reporting
Monitor progress against LTC LIS targets and outcomes. Produce reports on call and recall activity, review completion rates and MDT outcomes. Escalate risks relating to performance, patient engagement or service delivery. Support practices and PCN teams to achieve contractual and quality requirements Key Collaborative Working Relationships
PCN Leadership and Management Team
GPs, Practice Managers, nurses and other practice staff
Clinical Pharmacists
Social Prescribers
Community Services
Mental Health Professionals
Adult Social Care
Voluntary Sector
Secondary Care Partners
Person Specification
Qualifications Essential
Grade C GCSE English and Maths or equivalent qualifications Minimum of 2 years experience working directly with people, families or carers in health, social care or a related support role, whether paid or voluntary Good communication skills (written and oral) Good interpersonal skills including observation, listening and empathy Intermediate IT skills, able to use Microsoft Office applications, e.g. Word, Excel and PowerPoint Ability to manage multiple priorities Demonstrates attention to detail, accuracy and numeracy skills Ability to work as a team member and autonomously Excellent organisational time management skills
Desirable
MDT administration and minute taking Knowledge of LTC management programmes, QOF/LIS requirements Understanding of personalised care and care planning Population health management and data reporting Knowledge and ability to use GP IT system EMIS Web
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 Hornchurch Healthcare
Address Havering Liberty PCN
St George's Health and Wellbeing Hub
113 Sutton Lane
Hornchurch
Essex
RM12 6RR
United Kingdom
Employer's website https://www.hornchurchhealthcare.co.uk/ (Opens in a new tab)