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.
There will usually be a single point of access to ensure that people receive the right support at the right time. This single point of access will generally be via the social prescribing link worker(s), who will work in partnership with the care coordinator and a health and wellbeing coach to triage referrals. A care coordinator will work with a caseload of patients at any one time, acting as a central point of contact but is important they work with people in a way that enables them to move on. This might involve referring them back/onto to a health and wellbeing coach for support to build up their knowledge, skills and confidence in managing their condition, or to a social prescribing link worker to provide them with further support and connections into the voluntary and community sector.