PCN MDT and Integrated Care Coordinator


Company:	NHS Jobs
Salary:	Negotiable
Hours:	Full-time
Location:	Newham, E16 4QH
Job type:	Permanent
Posting date:	4 Sept 2026
Closing date:	27 Sept 2026

Apply for this job

Summary

Role Purpose The MDT Coordination, Clinical Care Coordination and Integrated Care Manager will support South One PCN to deliver high quality, proactive, and integrated care for patients with long-term conditions (LTCs). The postholder will: Coordinate and optimise Multi-Disciplinary Team (MDT) working Provide clinical care coordination across pathways The role ensures effective delivery of the LTC Proactive Care and Quality and Outcomes Framework (QOF) through jointed-up, person-centred, and data-informed care, improving outcomes and reducing health inequalities. Key Duties and Responsibilities (LTC Proactive Care QOF Aligned) MDT Coordination and Delivery Coordinate and support regular, structured MDT meetings for South One PCN, ensuring alignment with LTC Proactive Care QOF requirements. Organise MDTs at practice, neighbourhood, PCN, RPN or Borough levels as locally determined. Ensure MDT meetings are focused on high-need patients and result in clear actions, ownership, and follow-up. Maintain consistent MDT processes, agendas, case selection, documentation, and tracking outcomes. Clinical Care Coordination Coordinate care for patients discussed within MDTs, ensuring timely follow-up of agreed actions and interventions. Act as a central point of coordination between primary care community services, social care, and voluntary sector partners. Support navigation of patients through complex care pathways, improving continuity and reducing fragmentation of care. Ensure personalised care plans or implemented, reviewed, and updated in collaboration with MDT members. Identify gaps in care and escalate concerns appropriately to clinical leads. Supports proactive management of patients at risk of deterioration, admission, or poor outcomes. Identification and Proactive Management of LTC Patients Support identification and prioritisation of patients with multiple LTCs, frailty, or high risk. Ensure MDT discussions focus on high-risk and complex cohorts in line with QOF indicators. Facilitate development and review of proactive, personalised care plans Person-Centred and Integrated Care Enable MDTs to deliver holistic, person-centred care planning covering physical, mental, and social needs. Promote shared decision making and continuity of care. Ensure MDT actions translate into coordinated and effective care delivery across South One PCN. Effective MDT Working and Professional Collaboration Facilitate collaboration between primary care, community services, social care, and voluntary sector organisations. Ensure appropriate professional representation within MDTs . Promote Integrated ways of working to reduce duplication and improve patient experience. Health Inequalities and Targeted Support Ensure MDT And care coordination activity targets patients with health inequalities or barriers to access. Support production of on warranted variation across the South one PCN population. Align work with prevention, early intervention, and neighbourhood priorities. Quality, Outcomes and Continuous Improvement Monitor MDT activity and care coordination effectively against LTC proactive care quote indicators. Support collection of evidence demonstrating improvement in patient outcomes and service delivery. Use data, feedback column and learning to drive continuous improvement. Governance, Reporting and Assurance Support delivery assurance for the LTC Proactive Care QOF within South One PCN. Provide reporting to PCN leadership, RPN, and ICB. Act as a key point of contact for MDT and care coordination-related performance matters.

Apply for this job