PCN Care Co-ordinator


Company:	NHS Jobs
Salary:	Negotiable
Hours:	Full-time
Location:	Truro, TR4 8QS
Job type:	Permanent
Posting date:	7 Sept 2026
Closing date:	21 Sept 2026

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Summary

Key Responsibilities Care Coordination Coordinate and support the delivery of personalised care plans. Act as a central point of contact for patients and their families where appropriate. Support patients to access the right services at the right time. Coordinate care across primary care, secondary care, community services, social care and voluntary sector organisations. Facilitate smooth transitions between services. Ensure patients receive timely follow-up and ongoing support. Provide assessment within patient home settings. Patient Identification and Case Management Identify patients who may benefit from care coordination including: Frail and elderly patients. Patients with multiple long-term conditions. Patients experiencing frequent hospital admissions. Patients with complex social needs. Patients requiring support from multiple agencies. Maintain patient caseloads and prioritise support according to need. Monitor progress against agreed care plans. Escalate concerns and risks appropriately. Personalised Care Support Work alongside patients to identify their needs, goals and preferences. Support shared decision-making. Promote self-management and patient activation. Support patients in understanding available healthcare and community resources. Assist in developing personalised care and support plans. Multidisciplinary Team Working Participate in multidisciplinary team (MDT) meetings. Coordinate actions arising from MDT discussions. Support communication between clinicians, practices, community teams and partner organisations. Facilitate information sharing in accordance with information governance requirements. Frailty and Long-Term Condition Support Support proactive management of patients identified through frailty, population health and risk stratification programmes. Assist with long-term condition reviews and follow-up. Coordinate annual reviews where appropriate. Support implementation of PCN and Integrated Care System initiatives. Social Prescribing and Community Support Work closely with Social Prescribing Link Workers. Assist patients to access community-based services and support networks. Signpost patients to appropriate statutory and voluntary sector services. Support reduction of social isolation and health inequalities. Hospital Admissions and Discharge Support Support patients following discharge from hospital. Assist with post-discharge follow-up activity. Coordinate actions arising from discharge summaries. Identify patients at risk of avoidable admission and work with the wider MDT to provide support. Data Management and Reporting Maintain accurate patient records using clinical systems. Record activity in accordance with PCN, INT and contractual requirements. Produce reports and performance information as required. Ensure documentation is accurate, contemporaneous and compliant with information governance standards. Safeguarding and Risk Management Recognise and respond appropriately to safeguarding concerns. Follow local safeguarding procedures for children and adults. Escalate clinical and non-clinical risks promptly. Maintain patient confidentiality at all times. Service Development Contribute to continuous quality improvement initiatives. Participate in service evaluation and audit activities. Support implementation of new pathways and services. Share best practice and contribute to innovation across the PCN.

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