Long Term Conditions Care Co-Ordinator

Posting date:	28 August 2025
Salary:	Not specified
Additional salary information:	Negotiable
Hours:	Full time
Closing date:	12 September 2025
Location:	Carlisle, CA2 7AJ
Company:	NHS Jobs
Job type:	Permanent
Job reference:	A2260-24-0006

Summary

The primary focus of this role is to provide support to patients, aged 18 years and over, with a long term condition, engaging patients in their care and encouraging improved results and better health outcomes. The role will support the Practices within the PCN to deliver against the PCN Direct Enhanced Service (DES) specification, working in partnership with clinical and non-clinical colleagues, to ensure delivery of the best possible outcomes for our patients. The work contributes to supporting the Practices to meet QOF and KPI criteria. The job description does not provide an exhaustive list of tasks and activities. KEY RESPONSIBILTIES OF THE POST Work with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes. Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care. Work collaboratively with clinicians and other primary care professionals within the PCN to proactively identify and manage a caseload of patients with long-term conditions, and, where appropriate, refer back to other health professionals within the PCN. Support the coordination and delivery of multidisciplinary teams within the PCN practices. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations. Work with people, their families, carers and healthcare team members to encourage effective help-seeking behaviours. Support the PCN in developing communication channels between the practices, people and their families and carers and other agencies. Conduct follow-ups on communications from out of hospital and in-patient services. Maintain records of referrals and interventions to enable monitoring and evaluation of the service. Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the persons circumstances. Contribute to risk and impact assessments, monitoring and evaluations of the service. Work with commissioners, integrated locality teams and other agencies to support and further develop the role. MAIN DUTIES 1. Enable access to personalised care and support a. Take referrals for individuals or proactively identify people who could benefit from support through care co-ordination b. Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs c. Work towards increasing patients understanding of how to manage and develop health and wellbeing through offering advice and guidance d. Develop an in-depth knowledge of the local health and care infrastructure and know how, and when, to enable people to access support and services that are right for them e. Use tools to measure peoples levels of knowledge, skills and confidence in managing their health and to tailor support to them accordingly f. Support people to develop and implement personalised care and support plans g. Review and update personalised care and support plans at regular intervals h. Ensure personalised care and support plans are communicated to clinicians and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes 2. Coordinate and integrate care a. Making and managing appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations b. Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through the wider health and care system c. Refer onwards to social prescribing link workers and health and wellbeing coaches where required d. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported e. Actively participate in multidisciplinary team meetings in the PCN as and when appropriate f. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns g. Record what interventions are used to support people, and how people are developing on their health and care journey h. Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation i. Work sensitively with people, their families and carers to capture key information, while tracking of the impact of care coordination on their health and wellbeing j. Encourage people, their families and carers to provide feedback and to share their stories about the impact of care coordination on their lives k. Record and collate information according to agreed protocols and contribute to evaluation reports required for the monitoring and quality improvement of the service 3. Professional development a. Work with a named clinical point of contact for advice and support b. Undertake continual personal and professional development, including mandatory training, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required c. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety 4. Miscellaneous a. Establish strong working relationships with clinicians and practice teams and work collaboratively with other care coordinators, social prescribing link workers and health and wellbeing coaches, supporting each other, respecting each others views and meeting regularly as a team b. Act as a champion for personalised care and shared decision making within the PCN c. Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner d. Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning e. Contribute to the development of policies and plans relating to equality, diversity and reduction of health inequalities f. Work in accordance with the practices and PCNs policies and procedures g. Contribute to the wider aims and objectives of the PCN to improve and support primary care h. Ability to cope with challenging and stressful situations 5. Clinical skills a. Obtaining baseline observations for cohort of patients with long-term conditions b. Sample bloods, and process urine samples, relevant to cohort of patients related to annual review, and ongoing management, of long-term conditions c. Undertaking other relevant tests, such as diabetic foot checks and spirometry, etc, when suitably trained and within own competency for cohort of patients with long-term conditions COMMUNICATION Communicate effectively to overcome communication barriers with patients. Have the ability to communicate effectively with a wide range of people both verbally and written. To source, develop and manage a range of contact details and sources of information and services relevant to the local community and to make this accessible to other PCN staff. CONFIDENTIALITY The post holder must maintain strict confidentiality in all matters relating to patients, their families, and carers, as well as organisational and staff information. Information obtained in the course of duties must not be disclosed to any unauthorised person or used for personal gain. This includes verbal, written, and electronic records. All patient information must be handled in accordance with current data protection legislation, confidentiality policies, and professional codes of practice. Breaches of confidentiality will be regarded as a serious disciplinary matter. EQUALITY & DIVERSITY The post holder will support the equality, diversity and rights of patients, carers and colleagues, acting in a way that recognises the importance of peoples rights, respecting their privacy and dignity. HEALTH & SAFETY To take reasonable care for the health and safety of yourself and other people who may be affected by your actions or omissions Identify risks involved in work activities and undertake activities in a way that manages any risk Be aware of site health and safety policies and how to report incidents