Care Co-ordinator in London inLondon PUBLISHED MON 9 JUN 2025 Jump to job information section

Ensure accurate coding and records are kept, reviewed and monitored, coordinate care planning, and ensure effective communication among different care teams. Organise and managed huddles and MDT meetings, follow up on actions, and ensure continuity of care. Be part of the recall and referrlas team.

1. Assessment and Planning

   • Conduct or contribute to assessments of patients' health and social care needs.

   • Develop personalised care plans with input from the patient, family, and other professionals.

2. Coordinating Services

   • Act as the main point of contact for the patient, helping them access various services (e.g., GPs, social services, mental health teams).

   • Ensure communication between different parts of the health and care system.

3. Monitoring and Reviewing Care

   • Regularly review care plans to ensure they remain relevant.

   • Adjust support as the patient's condition or circumstances change.

4. Advocacy and Support

   • Help patients understand their care options and make informed decisions.

   • Ensure the patient's voice is heard in planning and decision-making.

5. Multidisciplinary Collaboration

   • Work closely with doctors, nurses, social workers, therapists, and others.

   • Attend multidisciplinary team (MDT) meetings to discuss cases and ensure coordinated care.

6. Documentation and Reporting

   • Keep accurate records of assessments, care plans, and interactions.

   • Report concerns or changes in patient condition promptly.

7. Promoting Independence

   • Support patients in managing their own care where appropriate.

   • Encourage self-care and access to community support.

• People with long-term conditions

• Those with mental health issues

• Patients with multiple health needs

• Older adults or individuals needing social care coordination

About us

. Patient Support & Coordination

• Identify patients who would benefit from care coordination (e.g. elderly, frail, frequent attenders, or with multiple conditions).

• Serve as the main contact point for patients and their carers regarding their care journey.

• Build trusted relationships with patients, encouraging self-management where possible.

2. Personalised Care Planning

• Work with patients to co-create personalised care plans tailored to their health needs and life goals.

• Ensure plans reflect patient preferences, involving family or carers when appropriate.

• Schedule and coordinate regular reviews of care plans.

3. Navigation & Signposting

• Help patients access appropriate servicesboth NHS (e.g., clinics, community nurses) and non-NHS (e.g., social prescribing, voluntary sector).

• Signpost patients to relevant community resources or support groups.

4. Multidisciplinary Team (MDT) Working

• Collaborate closely with GPs, nurses, pharmacists, social prescribers, health coaches, and other practice or Primary Care Network (PCN) staff.

• Attend regular MDT meetings to discuss complex patients and ensure joined-up care.

5. Proactive Population Health Management

• Use data and digital tools (e.g., patient registries, risk stratification software) to identify groups who need targeted interventions.

• Support proactive care, not just reactive appointments.

6. Administration & Record-Keeping

• Keep detailed and accurate records of all patient interactions, updates to care plans, and referrals.

• Update clinical systems (like EMIS or SystmOne) with care coordination notes and plans.

7. Health Promotion & Preventative Care

• Encourage and support patients in attending health checks, screenings, and vaccinations.

• Promote healthier lifestyles in line with NHS guidance.