Care coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services. Care Coordinators provide extra time, capacity, and expertise to support patients in preparing for, or in following-up, clinical conversations they have with primary care professionals.

They work closely with GPs and other primary care professionals within the PCN to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carer’s and ensuring that their changing needs are addressed. This is achieved by bringing

together all the information about a person’s identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.

Training/Development

Care Coordinators require a strong foundation in enabling and communication skills as set out in the core Curriculum for Personalised Care. These can be achieved via a two day health coaching skills course and additional training as guided by Health Education England. For further information on this guidance: https://www.hee.nhs.uk/our-work/health-coaching

Care coordinators should also access statuary and mandatory training, including but not limited to:

  • Principles of information governance, accountability and clinical governance
  • Maintenance of accurate and relevant records of agreed care and support needs
  • Identify when it is appropriate to share information with carers.
  • The professional and legal aspects of consent, capacity, and safeguarding

Care Coordinators should also be familiar with the six components of the universal model for personalised care with a specific focus on:

  • Support for self-management
  • Personalised care and support planning
  • Shared decision making
  • Personal Health Budgets

Benefits of the role

  • Care coordinators are the patient’s go-to person if their needs change or if something goes wrong with service delivery. The care coordinator ensures that there are no gaps in the patient’s service provision as many elderly and disabled people with highly complex needs struggle to coordinate with all the relevant services directly on their own.

 

  • Care coordinators help improve patient education and understanding and overall better health outcomes.
  • Patients can eliminate unnecessary appointments, procedures and tests – Patients feel more empowered and actively engaged in their treatment
  • A more seamless service provision significantly decreases the risk of the patient deteriorating and thereby reduces the overall cost of care and the likelihood that additional interventions will be needed in future.
  • By identifying high-risk patient populations before they incur costlier medical intervention, employers can begin to reduce both practice expenses and total NHS costs.
  • Employers can gain access to additional data that can reveal practice population health levels and risks – Care coordinators glean information about patients’ treatment histories, medication adherence, new symptoms and management of chronic conditions.
  • As part of the additional roles reimbursement scheme (ARRS) from April 2020, this role is able to be reimbursed at 100% of actual salary plus defined on-costs, up to the maximum reimbursable amount of £29,135 over 12 months.