Job Description

THE EMPLOYING ENTITY IS: CENTRAL LONDON HEALTHCARE CiC

The MDT Care Coordinator supports the delivery of joined‑up, proactive care for patients with complex health and social needs. The role ensures patients are prepared for MDT discussion, actions are followed through, and communication between professionals, services, and patients is clear and timely.

The postholder acts as a central point of contact, helping patients navigate the system, reducing duplication, and ensuring no one falls through gaps in care.

2. Key Responsibilities

A. MDT Preparation & Coordination

• Identify and prepare patients for MDT discussion using agreed criteria.
• Gather relevant clinical, social, and care information ahead of meetings.
• Liaise with GPs, CNs, CCs, social care, mental health, and voluntary sector partners.
• Ensure consent is obtained and recorded before MDT discussion.
• Produce agendas, circulate meeting papers, and support smooth running of MDT sessions.

B. Post‑MDT Follow‑Up

• Record MDT outcomes and ensure actions are allocated to the correct professionals.
• Track progress of actions and escalate delays or risks.
• Update patient records with clear, accurate documentation.
• Communicate outcomes to patients, carers, and relevant services.

C. Patient Support & Navigation

• Act as a named point of contact for patients with complex needs.
• Support patients to understand their care plans and next steps.
• Coordinate referrals, appointments, and follow‑up tasks across services.
• Help patients access community, social care, and voluntary sector support.

D. Proactive Care & Population Health

• Support practices with proactive care reviews and quarterly review cycles.
• Work with CCs and CNs to identify patients at risk of deterioration.
• Contribute to neighbourhood‑level population health initiatives.
• Support the pilot phase of MDT development and help refine processes.

E. Communication & Partnership Working

• Build strong working relationships with GP practices, social care, mental health, community nursing, and other MDT partners.
• Ensure timely information‑sharing in line with IG requirements.
• Participate in neighbourhood meetings, training, and development sessions.

F. Administration & Data Quality

• Maintain accurate records, trackers, and dashboards.
• Support reporting requirements for the Proactive Care specification.
• Ensure data is handled in line with GDPR and NHS IG standards.

3. Skills & Experience Required

Essential

• Experience working in primary care, community services, or a similar health/social care setting.
• Strong organisational and coordination skills.
• Excellent communication skills with patients and professionals.
• Ability to manage competing priorities and work independently.
• Understanding of confidentiality, consent, and information governance.
• Confident using clinical systems (EMIS/SystmOne) and Microsoft Office.

Desirable

• Experience supporting MDTs or complex case management.
• Knowledge of local health, social care, and voluntary sector pathways.
• Experience working with vulnerable or complex patients.
• Training in care navigation or care coordination.

4. Behaviours & Values

• Compassionate, patient‑centred approach.
• Collaborative and solution‑focused.
• Respectful, professional, and able to handle sensitive situations.
• Committed to improving patient experience and reducing inequalities.

5. Additional Information

• The role may require working across multiple practice sites.
• The postholder will be expected to participate in ongoing training, including MDT development, care navigation, and population health approaches.
• This role is part of a developing MDT model and may evolve as the pilot progresses.

Benefits

• Cycle to work scheme
• Discretionary pay progression and bonus scheme
• Employee Assistance Program (EAP)
• Enhanced annual leave entitlement (30 days full-time, pro-rata for part-time)
• Eye care voucher scheme through partnership with Specsavers
• Free tea/coffee etc.
• Life Assurance scheme
• Modern clinic at South Westminster Centre
• Modern office
• NHS Pension
• Refer & Earn scheme
• We Care Wellbeing through Canada Life including 24/7 GP access for employee and immediate family, Toothfairy Dentist on Demand, myStrength personal wellbeing support and CBT Therap