Care Coordinators work as advocates for specific groups of patients, such as people who are frail or living with severe mental illness. They support people to navigate their care journey and ensure those most affected by health inequalities can benefit from personalised care and support.  

They coordinate information on patients at their GP surgery or surgeries and proactively find patients with complex conditions or needs who may benefit from extra support.  

They are a main point of contact between these patients and the services involved in their care, supporting person centred decision making and streamlining information for both clinicians and the patient.  

As part of this, a care plan is developed to address the patient’s clinical and non-clinical needs, which could involve referring onto a Social Prescribing Link Worker and/or a Health and Wellbeing Coach.

Referrals to Care Coordinators can be made from a wide range of professionals within the PCN, including doctors, nurses, social prescribing link workers or health and wellbeing coaches.  

They can also be  linked to care homes, where they support the care of residents by helping communication between the GP surgery and social care services as well as other agencies.