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Care Coordinators: Bringing together personalised, proactive health care for everyone

Since their introduction three years ago, Primary Care Networks – or PCNs – have been working away at how best to offer personalised, proactive health care to patients.

We know that a ‘one size fits all’ approach doesn’t work because our population is growing, getting older with needs that change.

The care we offer needs to adapt to meet those changing needs, be joined up and consistent, and have patients at the centre of it. Care Coordinators play a vital role in helping us do that.

Who Care Coordinators work with

Improving the overall health and well-being of everyone in the network is one of the aims of each PCN. Anyone may meet Care Coordinators at some point.

All patients will fit into one of three broad groups, which might determine the different ways you’ll come across care coordination.

This video explains more:

For the biggest group of patients, those generally in good health, those interventions are likely to promote good health and help people make informed choices to stay well.

A programme like cervical screening, which aims to identify and treat potential risk factors before they become serious, is a good example.

Around 30% of people have long-term physical or mental health conditions, and Care Coordination supports these people with the support, knowledge, and confidence to manage their health effectively. Health coaching would be a good example.

The third much smaller group – around 5% – is those with complex needs and multiple long-term conditions. The level of intervention here is more intense, ensuring that all aspects of care and support are integrated to help people live as independently as possible and reduce avoidable hospital admissions.

Personalised Care

Personalised care is, of course, about making sure that each person gets access to the support and service that meet their individual needs. But it is also about taking into account and understanding people’s preferences, their personal circumstances and questions or worries they may have about their health.

This is the ‘what matters most’ approach.

Care Coordinators have the time, capacity, and expertise to help patients prepare for clinical conversations and support them through any follow-up.

For instance, when speaking to someone to book a cervical screening appointment, the conversation is about more than just scheduling.

It’s about understanding someone’s point of view and past experiences, listening actively without judgement, and offering information and advice that can help with specific worries or fears.

Each Care Coordinator will also have a caseload of patients who have been identified as benefiting from additional support. By working closely and collaboratively with patients and their families or carers, Care Coordinators can help ensure patients’ changing needs are met.

A Day in the Life of a Care Coordinator

Sarah, a Care Coordinator in North Gosforth Primary Care Network, runs us through a typical day for her.

Where Care Coordinators fit in

Care Coordinators are a key part of each Primary Care Network’s team of specialists. They work closely with Social Prescribers, Physios, Clinical Pharmacists, and GP practices.

As well as having the time to find out what matters most to each patient, they can act as the single point of contact. That means there is a named person for patients to speak to and a single figure to make sure referrals are sent and responded to, appointments booked, and health records updated.

Making sure that a person’s care is integrated and joined up means we can deliver consistent, effective, and personalised care to patients.