Overview of the role
Care Coordination enriches the skill mix of primary care teams. Care coordinators will play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with multiple long-term physical and mental health conditions, to provide coordination and navigation of care and support across health and care services and/or through primary care and secondary care.
The care coordinator role will ensure patient health and care planning is timely, efficient, and patient-centred. This is achieved by bringing together all the information about a person’s identified care and support needs and exploring options to meet these.
- The care coordinator will work with people individually, building trusting relationships, listening closely and working with them to develop a personalised care and support plan, based on what matters to the person.
- They will review people’s identified needs and help to connect them to the services and support they require, whether within the practice or elsewhere – for example, community and hospital-based services.
- They may support people in preparing for or following up clinical conversations they have with healthcare professionals, to enable them to be actively involved in managing their care and supported to make choices that are right for them.
Care co-ordinators are effective in bringing together multidisciplinary teams to support people’s complex health and care needs and support a joined-up way of working. They can facilitate referrals and conversations to ensure timely care and access to specialists, GPs, community services etc. In many cases they play a role in the initial set up of an MDT and championing a proactive approach to people’s care. As care co-ordinators act as a single point of contact for people they are a crucial link for teams, including staff in care homes, primary care, community care and secondary care.
NHS England DES Contract Specification 2025/2026 – PCN Requirements and entitlements