MMWF              
Primary Care  Network

Care Co-Ordinators

Care co-ordinators provide extra time, capacity, and expertise to support patients in preparing for or in following-up clinical conversations they have with primary care professionals. They will work closely with the GPs and other primary care professionals within the Primary Care Network (PCN) to identify and manage a caseload of identified patients(Frailty, Falls, Diabetes etc.) making sure that appropriate support is made available to them and their carers and ensuring that their changing needs are addressed. They focus delivery of the Comprehensive Model for Personalised Care to reflect local priorities, health inequalities or population health management risk stratification.

Care coordinators are one of several new roles that support the NHS’s commitment to improve health through personalised care. They do this by:

Providing a more joined-up and coordinated care journey for patients, instead of each encounter with services being seen as a single, unconnected ‘episode’ of care.

Acting as a single point of contact for patients to navigate the health and care system.

Breaking down traditional barriers between health and care organisations, teams and funding streams, to support the increasing number of people with long-term health conditions.

The work with practice managers to implement NHS DES requirements such as, Access, Early Cancer Diagnosis etc.