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.


From April 2020, this role will be reimbursed at 100% on the Additional Roles Reimbursment Scheme for PCNs. The Network Contract Directed Enhanced Service – Contract Specification 2021/22 provides reimbursement for three personalised care roles based in PCNs: social prescribing link workers, health and wellbeing coaches, and care coordinators. Supporting information on these three roles can be found in the Network Contract Directed Enhanced Service (DES) Guidance 2020/21.


A PCN’s Core Network Practices must identify a first point of contact for general advice and support and (if different) a GP to provide supervision for the PCN’s Care Coordinator(s). This could be provided by one or more named individuals within the PCN.

A PCN will ensure the PCN’s Care Coordinator(s) can discuss patient related concerns and be supported to follow appropriate safeguarding procedures page 91 (e.g. abuse, domestic violence and support with mental health) with a relevant GP.

A PCN must ensure that all staff working in practices that are members of the PCN are aware of the identity of the PCN’s Care Coordinator(s).


Where a PCN employs or engages a Care Coordinator under the Additional Roles Reimbursement Scheme, the PCN must ensure that the Care Coordinator completes;

A Personalised Care Institute (PCI) accredited care coordination course and/or a PCI accredited two day health coaching course. In considering which course would be most appropriate for their care coordinators, PCN managers are encouraged to consult the PCI website which provides details of accredited suppliers and courses available. See Accredited training (personalisedcareinstitute.org.uk)

In addition there are 3 short mandatory online modules from the Personalised Care Institute:

* Core Skills;

* Shared Decision Making;

* Personalised Care & Support Planning.

See Your learning options (personalisedcareinstitute.org.uk)


And Health Education England E-Learning for Health Platform’s Person Centred Approaches Programme, which is 5 hours in length, see Person-Centred Approaches – elearning for healthcare (e-lfh.org.uk)

Once in post, a Care Coordinator will be able to access the FutureNHS Collaboration Platform an NHS England online learning and support community – with Forums, Resources, National Webinar Series & “share and learn” sessions

Here at the Cambridgeshire & Peterborough Training Hub we encourage you to join us for a New to primary care induction. We aim to support your local Practice induction by providing a consistent and comprehensive introduction to working in Primary Care. And further regular ongoing training will be listed on our site under care-coordinator. When you register you will be able to sign up for regular newsletter updates with relevant training for your role.

And, we are privileged to be working with Care Network to provide an Induction into the Local Voluntary Sector in Cambridgeshire & Peterborough, weekly service updates & training opportunities from the local community and voluntary sector which will keep you connected to your colleagues working in personalised care across Cambridgeshire & Peterborough.

Further Information:

Click to find out more about the role of Care Coordinator, including job descriptions, case studies and more.

David Lynch (SPLW Cambridge City PCN) interview by the Healthy You Sports team at the City Council. David talks about social prescribing as well as his work as a wellbeing walk leader and mindfulness coach.