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, making sure that appropriate support is made available to them and their carers and ensuring that their changing needs are addressed. NHS England also advises to work closely and in partnership with Social Prescribing Link Workers or social prescribing service providers and Health and Wellbeing Coaches.
They focus delivery of the Comprehensive Model for Personalised Care to reflect local priorities, health inequalities or population health management risk stratification.
- Proactively identify and work with a cohort of people to support their personalised care requirements.
- Support people to use decision aids in preparation for a shared decision-making conversation.
- Bring together a person’s identified care and support needs and explore their options to meet these into a single personalised care and support plan, in line with person-centred service plan (PCSP) best practice.
- Help people to manage their needs, answering their queries and supporting them to make appointments.
- Support people to take up training and employment, and to access appropriate benefits where eligible.
- Raise awareness of shared decision making and decision support tools and assist people to more prepared to have a shared decision-making conversation.
- Ensure that people have good quality information to help them make choices about their care.
- Support people to understand their level of knowledge, skills and confidence (*patient Activation” level) when engaging with their health and wellbeing, including through use of the patient activation measure.
- Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing.
- Explore and assist people to access personal health budgets where appropriate.
- Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care roles.
- Support the coordination and delivery of MDTs within PCNs.
Care Coordinators should be based in a local cluster of General Practices as part of a Primary Care Network (PCN).
This role is intended to become an integral part of the PCNs multidisciplinary team, working alongside social prescribing link workers and health and wellbeing coaches to provide an all en-compassing approach to personlised care and promoting and embedding the personalised care approach across the PCN.
*The Patient Activation Measure helps to measure the spectrum of knowledge, skills and confidence in patients and captures the extent to which people feel engaged and confident in taking care of their condition.
- Be caring, dedicated, reliable and person - focussed and enjoy working with a range of people
- Have good written and verbal communication skills and strong organisational and time management skills
- Be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing people, their families and carers with high quality support
- Shared agenda setting
- Collaborative goal setting
- Shared follow up planning
- Using simple health literate communication techniques such as teach-back
- Structuring conversations using a coaching approach
- Knowledge of the core concepts and principles of personalised care, shared decision making, patient activation, health behaviour change, self-efficacy, motivation and assets-based approaches
Care Coordinators should also be familiar with the six components of the universal model for personalised care with a specific focus on:
- Social prescribing
- Personalised care and support planning.
- Support for self-management.
- Shared decision making.
- Personal Health Budgets.
Care Coordinators require a strong foundation in enabling and communication skills as set out in the core Curriculum for Personalised Care. Skills covered:
- Values in Personalised Care
- Capabilities in Personalised Care
- Core communication and relationship building skills
- Capabilities to engage people
- Capabilities to motivate, enable and support people
These can be achieved via a two day health coaching skills course.
e-Learning for Healthcare
The following resources can be accessed via e-Learning for Healthcare (e-LfH). E-LfH provides free e-learning programmes which can support you in your professional development.
If you do not already have an account, click here to register using your NHS email address. If you already have an account, please use the same link to firstly log in to access the following resources.
The below courses provide support surrounding the Universal Model for Personalised Care:
The below courses provide support surrounding the activities and requirements of a Care Coordinator:
- Care Certificate: This programme contains a range of resources relevant to this role, including frailty, infection prevention and control and mental health dementia and learning disability. You can review these sections independently or the programme as a whole by clicking the above link. This programme offers learning materials to support the development of knowledge, skills and behaviours required to achieve all 15 Standards of the Care Certificate.
- Person Centred Approaches: The aim of the course is to enable staff to behave in a person-centred way, based on the person-centred approaches framework, which aims to distil best practice and to set out core, transferable behaviours, knowledge and skills.
- Community Centred Approaches to Health Improvement: This course focuses on community-centred approaches to improving health and wellbeing.
- NHS e-Referral Service: The NHS e-Referral Service e-learning content will give NHS and healthcare staff a better understanding of NHS e-Referral Service (e-RS) and the functionality that is available to them.
- Effective Referrals to Other Clinical Teams: This session will cover what to think about before referring to other clinical teams and how to make effective referrals.
- Information Standard: This e-learning programme gives an introduction to what the Standard is, why it is important and why it might be relevant to your role.
- Physical Activity and Health: This course prepares GPs, nurses and other healthcare professionals to champion the benefits of physical activity with their patients and, in doing so, help prevent and manage a range of common physical and mental health conditions. This includes a useful section on promoting physical health in primary care.
- Making Every Contact Count: This session is designed to support learners in developing an understanding of public health and the factors that impact on a person’s health and wellbeing. It focuses on how asking questions and listening effectively to people is a vital role for us all.
- Supporting people with their mental health through social prescribing
This list is not exhaustive and the programmes available are regularly updated, so we recommend visiting the e-LfH portal and reviewing the available resources via using the “View full catalogue” function, or the “Search the e-learning" function.
Personalised Care Institute
Register with the Personalised Care Institute e-learning modules suitable as part of the induction process
• Core skills in personalised care
• Personalised care and support planning
• Supporting behaviour change
• Health literacy skills
As well as e-learning, the Personalised Care Institutes online platform contains discussion forums, webinars and news.
Future NHS
Register with Future NHS website using your NHS email address to access a range of workspaces and platforms such as the "Personalised Care Collaborative Network". This is where NHS England & Improvement share all the latest information and resources on personalised care.
On-Going Development
Some of the following mechanisms should be considered:
- Refresher sessions
- Buddying with peers
- One-to-one support from a practitioner with health coaching experience
- Action Learning Sets
- E-learning to revisit or deepen training
- Supervision
A PCN's Core Network Practices must identify a first point of contact for general advice and support and (if different) a GP to provide supervision. Care co-ordinators should be able to discuss patient related concerns and be supported to follow appropriate safeguarding procedures. This could be provided by one or more of the following individuals within the PCN:
- Health and Wellbeing Coach
- Social Prescribing Link Worker
- GP
- Physician Associate
- Other ACP (3+ years)
- Mental Health Practitioner
- Occupational Therapist
The Personalised Care Institute (PCI) launched September 2020 convened by the Royal College of General Practitioners has the primary role of setting the core curriculum and training standards for all healthcare staff in personalised care, based on the Universal Personalised Care Model.
PCNs should ensure that training for care coordinators is provided only by PCI who will also develop and establish an assurance process for training providers, a register of assured providers and a single point of access for e-learning in personalised care.
More information surrounding supervision can be found here.
Educated to GCSE level or equivalent.
Currently enrolled in, undertaking or qualified from Personalised Care Institute appropriate training to obtain a level three standard.
Level 3 Diploma in Business Administration:
Health and Social Care Degrees:
Reimbursed at 100% of actual salary plus defined on-costs, up to the maximum reimbursable amount of £35,301 over 12 months. A PCN can also claim reimbursement for the time Care Coordinators spend out of practice undertaking some activities.
Research
NHS England produced a study around patient activation which could help over 1.5 million people in England with long term conditions. Patient activation can be used to reduce health inequalities and deliver improved outcomes, better quality care and lower costs.
This document, produced by NHS England, sets out how the NHS Long Term Plan commitments for personalised care will be delivered.
Tools for Practice
This infographic demonstrates the importance of personalised care and the link of this role to the relevant services.
North Cumbria Personalised Care Team and Yorkshire and Humber NHS England Regional Social Prescribing Team have compiled a list of available training courses and programmes to create a Personalised Care Roles Training Matrix & Personal Development document.
Employer Resources
These are the slides from a presentation given covering Personalised Care roles in Primary Care Network giving an overview of the roles, skills and competencies, training, supervision and support.
Role Overview
This updated DES 2024/25 outlines the role of the Care Coordinator and what is expected from PCNs (page 86-89).
Professional Bodies
The personalised care institute sets the standards for evidence-based personalised care training, providing a robust quality assurance and accreditation framework for training providers and commissioners, with a central learning hub for health and care professional learners.
Jobs
If you are looking for a new position related to this role, we recommend checking both NHS Jobs and HealthjobsUK.
NHS Jobs is the official online recruitment service for the NHS in England and Wales, with over 30,000 jobs posted every month.
Hosted by trac.jobs, HealthJobsUK is among the leading job boards in the health and public sector within the UK.
