Project Lead & Care Coordinator – Proactive Care Team (PACT)

  • Accountable to - GP Clinical Lead(s)
  • Salary - Dependent on experience

Job Summary

The Project Lead & Care Coordinator is responsible for supporting the delivery, coordination and ongoing development of the Proactive Care Team (PACT) across the Primary Care Network (PCN). The role aims to improve outcomes for patients with complex health and social care needs through proactive, coordinated and person-centred care, ensuring patients receive the right support at the right time from the most appropriate services.

Working closely with the GP Lead, the post holder will provide day-to-day operational oversight of the service, coordinating patient care, supporting project delivery and monitoring performance against agreed objectives and targets. This includes overseeing patient caseloads, ensuring timely follow-up and review, coordinating multidisciplinary working and supporting the continuous development of the service.
A key element of the role is coordinating and facilitating multidisciplinary team (MDT) meetings involving General Practice, Community Services, Adult Social Care, Mental Health Services, Acute Trusts, Hospital at Home, District Nursing teams, Voluntary Sector Organisations and others. The post holder will identify patients requiring MDT review, coordinate meeting processes and ensure agreed actions and outcomes are progressed.

The role also includes responsibility for service reporting, data monitoring and quality improvement activities, including the collection, analysis and submission of activity and outcome data to support PCN and Integrated Care Board (ICB) reporting requirements. Working alongside project and clinical leads across partner practices, the post holder will support a consistent and collaborative approach to service delivery.

The post holder will provide line management and supervision for Care Coordination staff, supporting workload management, professional development and wellbeing. They will work across organisational boundaries to build effective relationships with health, social care and voluntary sector partners, advocate for patients where required and contribute to reducing health inequalities through integrated, preventative and personalised approaches to care.

 

Primary Duties and Areas of Responsibility

Project Leadership and Operational Management

  • Support the day-to-day operational delivery of the Proactive Care Team (PACT).
  • Work alongside the GP Lead to oversee project delivery, service development and continuous improvement.
  • Monitor patient activity, caseloads and service performance to ensure agreed objectives, targets and timescales are met.
  • Allocate patient visits and associated work across the multidisciplinary team, including GPs, Paramedics and Care Coordinators.
  • Ensure proactive follow-up and review of patients in line with agreed pathways.
  • Organise team meetings and contribute to service planning, development and quality improvement.

Line Management Responsibilities

  • Provide line management, supervision and day-to-day operational support to Care Coordinators.
  • Conduct one-to-one meetings, appraisals and performance reviews.
  • Manage annual leave, sickness absence and workload allocation.
  • Support staff wellbeing, training and professional development.
  • Address performance issues appropriately and support improvement plans where required.

Multi-Disciplinary Team (MDT) Coordination

  • Coordinate and facilitate weekly MDT meetings involving primary care, community, mental health, social care, acute and voluntary sector partners.
  • Coordinate weekly patient review meetings with the GP Lead and attend daily operational meetings where required.
  • Identify patients requiring MDT discussion through proactive case finding and clinical review.
  • Prepare agendas, record and distribute minutes, monitor agreed actions and ensure timely follow-up.
  • Develop effective working relationships with partner organisations to support integrated patient care.

Patient Identification and Care Coordination

  • Identify patients who would benefit from proactive multidisciplinary intervention using information from primary, community and secondary care.
  • Coordinate care planning for patients with complex health and social care needs.
  • Act as a central point of contact for professionals involved in patient care.
  • Liaise with patients, carers and partner organisations to coordinate services, complete referrals and ensure agreed care plans are implemented.
  • Escalate concerns relating to patient safety, unmet need or service delays appropriately.

Information Systems, Data and Performance

  • Maintain accurate patient and service records using EMIS and other reporting systems.
  • Use clinical system searches and reporting tools to identify patient cohorts and monitor activity.
  • Maintain project databases and reporting templates.
  • Collect, validate and analyse activity and outcome data.
  • Produce monthly reports for the Integrated Care Board (ICB) and PCN partners.
  • Monitor performance against agreed targets and participate in commissioner and stakeholder meetings.

Communication and Collaborative Working

  • Develop and maintain effective working relationships with colleagues, partner organisations and external agencies.
  • Communicate effectively with patients, carers and professionals to support coordinated care.
  • Work collaboratively across the PCN, including Manor Surgery and partner services.
  • Provide information and updates to support MDT decision-making.
  • Manage competing priorities within a busy operational environment and act as an ambassador for the PACT service.

Quality Improvement and Service Evaluation

  • Support service evaluation through data collection, patient feedback, case studies and audits.
  • Monitor patient outcomes and identify opportunities to improve service delivery.
  • Work with the GP Lead and partners to implement quality improvement initiatives.
  • Share learning and examples of good practice across the service.

Supporting Delivery of PCN Services

  • Support delivery of proactive, personalised and integrated care across the PCN.
  • Contribute to initiatives that improve patient outcomes and reduce health inequalities.
  • Support service transformation, neighbourhood working and achievement of PCN priorities.

Patient Care and Service Coordination

  • Communicate sensitively with patients, carers and relatives, adapting communication to individual needs.
  • Promote patient involvement, independence and personalised care.
  • Coordinate actions arising from MDT discussions, including referrals, care planning and service liaison.
  • Monitor the progress of referrals and interventions, ensuring professionals remain informed and concerns are escalated appropriately.

Other Responsibilities

  • Work in accordance with organisational policies, professional standards and equality legislation.
  • Maintain mandatory training and continuous professional development.
  • Contribute to a safe working environment and comply with Health and Safety requirements.
  • Support service delivery across the wider locality where required.
  • Undertake any other duties appropriate to the role.

Autonomy and Scope of the Role

  • Work independently within organisational policies and agreed protocols, exercising judgement in the day-to-day management of the service.
  • Manage workload and priorities with minimal supervision while working closely with the GP Lead and key stakeholders.
  • Contribute to the ongoing development and improvement of the Proactive Care Team.
 

Key Relationships

Internal

  • GP Clinical Lead(s)
  • PCN Clinical Director
  • Practice Managers
  • Care Coordinator(s)
  • Paramedics
  • Administrative Teams

External (including but not exhaustive)

  • Manor Surgery Project Lead(s) and GP Lead(s)
  • District Nursing Teams
  • Hospital at Home Teams
  • Community Therapy Teams
  • Adult Social Care
  • Mental Health Services
  • Community Nursing Services
  • Acute Hospital Teams
  • Voluntary and Community Sector Organisations
  • Integrated Care Board (ICB)
  • Patients and Carers
  • Social prescribing link workers
  • Community Health & Wellbeing Workers

Health and Safety/Risk Management

  • The post-holder must comply at all times with the organisation’s Health and Safety policies, in particular by following agreed safe working procedures and reporting incidents using the organisation’s Incident Reporting System.
  • The post-holder will comply with the Data Protection Act, UK GDPR and the Access to Health Records requirements.
  • The post-holder will comply with all necessary training requirements relevant to the role as identified by the organisation.

Equality and Diversity

  • The post-holder must co-operate with all policies and procedures designed to ensure equality of employment.
  • Colleagues, patients and visitors must be treated equally irrespective of age, disability, gender reassignment, marriage and civil partnership status, pregnancy and maternity, race, religion or belief, sex or sexual orientation.

Respect for Patient Confidentiality

  • The post-holder should always respect patient confidentiality and not divulge patient information unless sanctioned by the requirements of the role.
  • Information relating to patients, carers, staff and partner organisations must be managed in accordance with current information governance requirements.

Special Working Conditions

  • The post-holder is required to travel independently between practice sites and partner organisations where applicable.
  • Attendance at meetings, training events and service development activities hosted by external agencies may be required.
  • Occasional flexibility in working arrangements may be required to support service delivery.
 

Job Description Agreement

This job description is intended as a guide to the scope and responsibilities of the post and is not exhaustive. As the service continues to develop, the role may evolve in line with organisational priorities, operational requirements and the experience of the post holder. The job description will be reviewed periodically and amended where necessary following consultation with the post holder.

 

Person Specification

Education, Qualifications and Training

Essential

  • Educated to Diploma, HNC level or equivalent experience.
  • Relevant qualification in Business Administration, Healthcare Administration, Project Management or equivalent experience.
  • Evidence of ongoing professional development.
  • Good understanding of the Personalised Care agenda within Primary Care Networks.
  • Competent in the use of Microsoft Office applications including Word, Excel, Outlook and Teams.

Desirable

  • Qualification or training aligned with the Personalised Care Institute Care Coordinator Framework.
  • Leadership or management training.
  • Project management training or experience.
  • Long-term conditions training.
  • Understanding of Population Health Management approaches.
  • Quality Improvement training or experience.

Experience and Knowledge Required

Essential

  • Experience working within Primary Care, the NHS, Health and Social Care, or a related healthcare setting.
  • Experience coordinating care for patients with complex health and social care needs.
  • Experience working within multidisciplinary teams.
  • Experience organising and coordinating meetings involving multiple stakeholders.
  • Experience maintaining accurate records and handling confidential information.
  • Experience using clinical systems and databases, including data extraction and reporting.
  • Experience collecting, analysing and reporting activity or performance data.
  • Experience managing competing priorities and working within a busy operational environment.
  • Understanding of integrated working across health, social care and voluntary sector organisations.
  • Understanding of the challenges facing Primary Care and the wider NHS.

Desirable

  • Experience of line management or staff supervision.
  • Experience of project coordination, service development or quality improvement initiatives.
  • Experience of preparing reports for commissioners, senior managers or external stakeholders.
  • Experience of working with frail, elderly or vulnerable patient groups.
  • Knowledge of PCN, Integrated Neighbourhood Team or Community Services models.
  • Understanding of reducing health inequalities and proactive care approaches.

Skills and Attributes

Essential

  • Excellent verbal and written communication skills.
  • Strong organisational and administrative skills.
  • Ability to prioritise workload effectively and work independently.
  • Strong interpersonal skills with the ability to build positive working relationships.
  • Ability to influence, negotiate and work collaboratively with a wide range of professionals.
  • Ability to lead and coordinate multidisciplinary meetings.
  • Ability to analyse and interpret information and present findings clearly.
  • Strong problem-solving and decision-making skills.
  • High level of accuracy and attention to detail.
  • Ability to manage sensitive and confidential information appropriately.
  • Competent in the use of data management systems and spreadsheets.
  • Ability to monitor performance and identify areas for improvement.
  • Ability to support, supervise and motivate team members.

Desirable

  • Experience using EMIS Web or similar clinical systems.
  • Experience producing performance reports and service evaluations.
  • Experience facilitating service improvement activities.
  • Understanding of NHS reporting and performance requirements.

Aptitude and Personal Qualities

Essential

  • Professional, approachable and confident manner.
  • Self-motivated and able to work with minimal supervision.
  • Flexible and adaptable to changing priorities.
  • Able to remain calm and effective under pressure.
  • Committed to delivering high-quality patient-centred care.
  • Ability to work collaboratively across organisational boundaries.
  • Proactive approach to identifying and resolving issues.
  • Commitment to equality, diversity and inclusion.
  • Strong sense of accountability and responsibility.

Desirable

  • Experience supporting organisational change.
  • Demonstrates leadership qualities and initiative.
  • Interest in service development and innovation.

Values, Drivers and Motivators

Essential

  • Commitment to improving outcomes for patients and reducing health inequalities.
  • Commitment to integrated working across health and social care organisations.
  • Commitment to continuous learning and professional development.
  • Passion for delivering proactive, personalised and preventative care.
  • Commitment to supporting colleagues and contributing positively to team development.
  • Understanding of the importance of patient dignity, choice and independence.

Other Requirements

  • Ability to travel independently between sites and attend meetings across the locality as required.
  • Willingness to undertake further training and development relevant to the role.
  • Flexible approach to working in a developing and evolving service.
 

How to apply

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