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What is Care Coordinators?

Care coordinators provide extra time, capacity, and expertise to support patients in preparing for clinical conversations or in following up discussions with primary care professionals. They work closely with the GPs and other primary care colleagues 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 (if appropriate), and ensuring that their changing needs are addressed.
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How Care Coordinators can help you...

  • Prepares patients for conversations about their health and care
  • Assesses and monitors health and care needs
  • Takes a personalised approach, focusing on what matters to patients most, using personalised care support planning tools (PCSPs)
  • Acts as the node of the GP surgery, being a single point of access for vulnerable patients with complex conditions
  • Supports tackling health inequalities by proactively identifying areas of unmet need for practices and specific patients to work with or refer onwards
  • Proactively identifies vulnerable or complex patients
  • Can be practice or PCN based, which means they may work on wider priorities across several practices or at just one practice

Care coordinators also strengthen links between the PCN/practice and services involved in care e.g. care homes, ambulance services, prevention programmes. They save GPs and other professionals time by ensuring information about a patient is streamlined and easily accessible and helps practices and PCNs in multidisciplinary team working by connecting individuals and supporting MDT meetings.

Elderly care home-medication
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"The social prescribers I saw at the surgery were very helpful, Knowledgeable with a good sense of humour"

Patient

''Couldn't do any better, very kind and helpful, Thank you so much''

Mrs B,

Patient

''They are doing an amazing job, Made me feel better and calmed me down''

Miss N,

Patient

''Suzi and Natalie are worth their weight in gold, we have seen them twice and they make you feel very welcome. They certainly know what they are talking about, thank you”

Patient

''That is such an amazing news, Thank you so much for your help, support and understanding, I can’t express how much I appreciate it''

Mrs J,

Patient

'Natalie, Thank you so much for helping us with the applications so quickly and for making all the referrals. You are a star and I really appreciate all your help.''

Mrs B,

Patient

''I just want to say a huge thank you to the social prescribing team who called me after a home visit from the GP. I have had to try and organise a carer for my In-Laws urgently and did not have a clue how difficult it would be. Suzi chatted through the types of care and the referral options in adult social care and guided me through the options. I received a prompt email providing links to PA providers. Great support from a knowledgeable team. Thank you.''

Mrs R,

Patient

How Aylesbury Central PCN delivers Care Coordinators...

We have a dedicated Care Co-Ordinator and Pharmacist who form part of our multi-disciplinary team (MDT) visiting care homes on a weekly basis. We are also lucky to be able to offer our patients who live in a care home the access to Immedicare, 24/7 365 day a week acute service with access to nurses and geriatricians.

Care Homes MDT

A care home multidisciplinary team (MDT) is a group of healthcare professionals who work together to provide care for residents of a care home. The team typically includes a range of professionals with different expertise, such as doctors, nurses, physiotherapists, occupational therapists, and social workers.

The goal of an MDT is to provide coordinated and comprehensive care for residents, taking into account their physical, psychological, and social needs.

“The MDT is really helping with the medication provision for the residents. You are very responsive to requests and there is an improvement in the medication ordering and delivery. So thank you very much for what you are doing.”

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We passionately believe in quality education and in long-term sustainable behaviour change and not short-term diet or lifestyle fads. We look at health holistically, offering choices with flexible options. This approach delivers multiple benefits well beyond weight loss including improving sleep quality, stress management, relationship with food and preventing future health conditions.

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