PCN Proactive Care Connector
Job Description
Job summary
The Proactive Care Connector will play a critical role in supporting our vulnerable and frail patient cohort.
Working within the PCN's Proactive Care Team, the role focuses on coordinating care across primary care, community health services, social care, and voluntary organisations to ensure patients receive timely, effective, and person-centred support.
A key aspect of the position is facilitating communication between patients, carers, GPs, healthcare professionals, and partner agencies to improve health outcomes and promote independence.
The role involves coordinating Multi-Disciplinary Team (MDT) meetings, supporting personalised care planning, managing referrals, conducting patient assessments, and helping individuals access appropriate services.
The Proactive Care Connector acts as an advocate for patients, identifies barriers to care, promotes healthy lifestyles, and helps ensure the delivery of seamless and proactive care across multiple services.
Main duties of the job
The Proactive Care Connector plays a key role in supporting vulnerable and frail patients through effective care coordination and multidisciplinary working. The role acts as a central point of contact for patients, carers, GP practices, community services, social care teams and voluntary organisations, ensuring individuals receive coordinated and person-centred care.
Key responsibilities include organising and supporting Multi-Disciplinary Team (MDT) meetings, maintaining patient records, processing referrals, undertaking screening calls and assisting with personalised care planning.
The role involves gathering and sharing relevant patient information to support timely decision making and proactive interventions aimed at preventing unnecessary hospital admissions.
The post holder is responsible for signposting patients to appropriate health, social care and community services, promoting healthy lifestyles, supporting self-management and helping patients overcome barriers to accessing care. Regular communication with patients, carers and professionals is required to monitor ongoing needs and ensure continuity of care.
The role also includes maintaining accurate electronic records, managing databases, producing reports, supporting audits and contributing to service improvement initiatives.
Strong organisational, communication and IT skills are essential,with the ability to prioritise, work independently and support the wider integrated care team in improving outcomes for patients.
About us
Armley Primary Care Network (PCN) is a partnership of three GP practices in West Leeds that work together to deliver high-quality, integrated healthcare services to a population of over 30,000 patients.
The network includes Armley Medical Centre, Priory View Medical Centre and Thornton Medical Centre, working collaboratively with community health services, social care, mental health teams and voluntary sector organisations to provide coordinated, person-centred care.
The PCN's vision is to integrate care and work better together to meet the needs of the local population. Key priorities include prevention, mental health, and supporting people living with physical and mental frailty through proactive care, intervention and multidisciplinary working.
Serving a diverse community with significant health inequalities and higher levels of long-term health conditions, Armley PCN is committed to improving health outcomes, reducing avoidable hospital admissions, and helping people remain independent within their own homes and communities.
Through effective partnership working and proactive care coordination, the PCN aims to ensure patients receive the right care, at the right time, from the right professionals.
Job responsibilities
Proactive care coordination and patient support
- Act as a central point of contact for patients, carers, and professionals involved in care delivery.
- Coordinate care across primary care, community services, secondary care, social care, and voluntary organisations.
- Support safe and effective transitions between hospital and community-based services.
- Signpost patients and carers to appropriate services, resources, and support networks.
- Assist in identifying sources of support for patients with complex health and social care needs.
- Build positive working relationships that encourage engagement and shared decision-making.
- Support the maintenance of frailty registers and proactive patient case management programmes.
Multi-disciplinary team (MDT) support
- Coordinate and facilitate regular Multi-Disciplinary Team (MDT) meetings across the Primary Care Network.
- Prepare, collate, and present relevant patient information to support effective discussion and care planning.
- Record meeting outcomes and ensure agreed actions are communicated and progressed appropriately.
- Work collaboratively with GPs, community services, social care teams, mental health services, and voluntary sector partners to support integrated care delivery.
- Attend MDT meetings, including those relating to frequent attenders and patients with complex needs, contributing to hospital admission avoidance initiatives.
- Support the development, monitoring, and review of care plans through a multidisciplinary approach.
- Facilitate communication between all professionals involved in patient care to ensure continuity and consistency of support.
Administrative support
- Manage and prioritise workload effectively within a busy integrated care environment.
- Coordinate the administrative functions associated with MDT meetings, including scheduling, documentation, and follow-up actions.
- Maintain efficient filing, record-keeping, and administrative systems.
- Receive and manage referrals, enquiries, and correspondence from health and social care professionals.
- Ensure patient information is recorded accurately and shared appropriately in line with information governance requirements.
- Support the development and implementation of administrative processes and standard operating procedures.
- Produce reports and documentation required to support service delivery and performance monitoring.
IT and data management
- Use a range of clinical and administrative systems to support patient care and service delivery.
- Maintain accurate electronic patient records and update systems following MDT discussions and care interventions.
- Extract, collate, and analyse patient information from multiple systems to support care planning and MDT decision-making.
- Maintain databases and registers relating to frailty, care coordination activity, and service performance.
- Produce statistical reports and performance data as required.
- Support the use of risk stratification tools to identify patients who may benefit from proactive intervention.
- Demonstrate proficiency in Microsoft Office applications, including Outlook, Word, Excel, Teams, and relevant clinical systems.
Audit, quality improvement and service development
- Contribute to audit, governance, and service improvement activities.
- Support the collection and analysis of data to inform performance monitoring and service evaluation.
- Participate in projects aimed at improving patient outcomes, reducing health inequalities, and preventing unnecessary hospital admissions.
- Assist in identifying opportunities to enhance care pathways and operational processes.
- Maintain awareness of current best practice and contribute ideas to support continuous improvement.
Learning and professional development
- Demonstrate a commitment to ongoing personal and professional development.
- Participate in regular supervision, appraisal, and performance review processes.
- Develop and maintain knowledge of local services, referral pathways, and integrated care systems.
- Identify training and development needs in conjunction with line management.
- Engage in formal and informal learning opportunities to enhance knowledge, skills, and competence within the role.
Person Specification
Qualifications
Essential
- NVQ Level 3 in Health and Social Care, Business Administration, Customer Care, or equivalent qualification and/or relevant experience.
- Evidence of ongoing professional development.
- Good standard of literacy and numeracy.
- Proficient in the use of Microsoft Office applications, including Word, Outlook, Excel and Teams.
Desirable
- Care Coordinator Training Programme or willingness to undertake relevant training.
- Qualification in Health and Social Care, Public Health, Community Development, or a ...
