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Creating an effective Care Coordination Service (focusing on the small things that make a big difference)
Updated: Nov 25
Here at THC Primary Care, we provide resources for PCN leaders, and this blog will focus on care coordination.
The role of the Care Coordinator and the development of this service continue to be a source of intrigue for many across general practice, and we receive many requests for further insight into what others might be doing and where the role can add value.
So, with this in mind, and as part of our Best Practice / THC Primary Care collaborative webinar series, I met with PCN Manager (and former Practice Manager) Sarah Cole from 4PCN in South Gloucestershire to discuss the following:
1️⃣ The 4PCN setup and patient demographic
2️⃣ Mapping patient demand and the importance of data
3️⃣ Establishing (and developing) a care coordination service
4️⃣ Defining the difference between a care coordinator and social prescribing link worker
5️⃣ Day-to-day responsibilities and tasks
6️⃣ Accessing the care coordination service
7️⃣ Key relationships and collaborators
8️⃣ Skills and qualifications required
9️⃣ Rates of pay
1️⃣ 0️⃣ Training and supervision considerations
1️⃣ 1️⃣ Opportunities for progression
1️⃣ 2️⃣ Measuring service impact (and the challenges related to this)
Let’s jump in!
An introduction to 4PCN
With a caseload of approximately 54,500 patients, spread across four practices, and a demographic mix of deprived communities and more affluent areas, 4PCN is based in South Gloucestershire, on the outskirts of Bristol.
The staffing cohort is split between those who are typically practice-based (pharmacists and pharmacy techs, physiotherapists, and the medical team) and staff, like the care coordinators, who are spread across the PCN.
Where to start…
Sarah explains that each year, via the medium of their annual board meeting, individual practice priorities are discussed, and common themes are mapped accordingly.
Despite the variation in size and dynamic between each practice within the 4PCN network, the team noted a demand for social and practical interventions, and a shared vision to de-medicalise care was developed. The idea being that the ‘softer’ issues are fixed before patients require medical attention from the GPs, or a hospital admission (and then the associated aftercare).
The increase in the ARRS budget proved to be timely, allowing 4PCN the financial flexibility to develop a care coordination team, and to realise their vision.
Establishment of the service
By utilising a small pot of allocated funding, 4PCN initiated a population health management project and as a result, appointed a care coordinator to initially focus on working with patients with dementia, with a record of hospital admissions.
Following an overwhelmingly positive response from the same patient cohort, who reported feeling greatly reassured by having a dedicated point of contact and the availability of someone from the practice to offer further support at home, the PCN worked towards increasing health checks for patients with serious mental illness and learning disabilities.
From there, the team took a leap of faith and moved fully into anticipatory care, in an effort to prevent patients with long-term health conditions and complex needs from requiring a hospital admission.
They are now aiming to expand the service further, to include patients with cancer, recognising the need for continuity of care and support.
🎯TIP Starting on a small scale is always a useful (and much safer) approach when it comes to piloting and developing new systems, processes, and services. Use your data to analyse and identify where you might be able to start.
Why choose a Care Coordinator over a Social Prescribing Link Worker?
Having utilised Social Prescribing Link Workers previously, 4PCN found that, whilst they were able to offer a useful service to patients in terms of providing information and resources, they weren’t able to be as hands-on as they needed.
Citing an example, Sarah recalls that a vast majority of patients with complex needs, learning disabilities and/or serious mental illness were simply too afraid to leave their homes or join new groups following the global pandemic.
A visible resource was needed to go into patients’ homes and attend appointments (and events) with them to build confidence and trust and, ultimately, to prevent further deterioration that may otherwise lead to a need for medical intervention.
Defining the day-to-day activities and responsibilities of a Care Coordination team
No Care Coordination team will be completely identical and in South Gloucestershire, the remit is wide-ranging, meaning no two days are the same.
Some examples of the types of things the Care Coordinators in 4PCN are involved with:
Undertaking basic health checks and screening such as diabetic foot checks, taking blood and checking in patients’ ears
Conducting home visits to support patients with practical and day-to-day tasks
Supporting patients with their mental health and wellbeing needs
Making referrals and taking notes
Liaising with clinicians and working collaboratively with the wider medical team
Overall, Sarah highlights the importance of building relationships and trust with patients, even if it means spending time on seemingly small tasks that make a big difference.
Referring into the service
In terms of structure, the anticipatory care team are assigned by practice, and patients are booked in as follows:
Following a proactive search to identify housebound patients and / or those with a high level of need who may require intervention.
Referral in from a clinician (usually in the form of a task assigned via the practice system).
The team meet regularly to discuss and review caseloads, to share experiences and challenges and ultimately, to nurture a safe and supportive environment.
Managing relationships and working collaboratively
As the emphasis on the role is to advocate for patients, the care coordination team should be given freedom to collaborate with various agencies, including district nurses, social services, and mental health organisations. Despite some initial resistance in some areas, Sarah reports that mutual respect has since developed over time in her area.
Care Coordinators should additionally be included in local MDTs within the primary care team.
What skills and qualifications should a Care Coordinator have?
Much like their daily responsibilities, the profile, previous experience, and skills required to be a Care Coordinator are richly diverse and fully dependent on the PCN’s needs.
Some sample profiles of the care coordinators recruited by 4PCN:
A young adult with severe autism whose input has been greatly valued because of his ability to fully understand the needs of his patients and the complexities of navigating healthcare systems.
A former charity worker with a strong administrative background who was able to identify gaps in the service.
A former practice receptionist who had long-established and trusted relationships with older patients, as a result of regularly speaking to them over the telephone.
Sarah’s feeling is that, so long as candidates have a relevant background in some way, a naturally warm rapport (and empathy) with people, and are willing to learn and perform basic health checks, the role can evolve from there.
Rate of Pay
In South Gloucestershire, the care coordinators are paid slightly more than an HCA, recognising that they are required to make proactive decisions related to progression of patient care and because of the uncertainties around what they may be walking into, in the context of the home visits they undertake.
Training and Supervision
As per the pay element, it is advisable to model training requirements on that of an HCA. All of 4PCN’s care coordinators hold their Care Certificate, for example.
4PCN also recommend utilising eLearning for Healthcare and the Personalised Care Institute to access free and relevant training around key topics such as suicide awareness, managing challenging conversations, and more.
Local councils can also provide useful training opportunities, such as general first aid and mental health first aid training.
In terms of supervision, the PCN clinical lead will hold ultimate responsibility however in Sarah’s network, where the care coordinators are practice-based, they report to the local Safeguarding lead, be it a GP, or nurse practitioner.
Finally, as the care coordinators additionally attend practice MDT meetings, they can be guided accordingly by their senior leads, to ensure they are progressing (rather than holding) patients appropriately.
Opportunities for progression
Sarah acknowledges that the ability to progress within the role is tricky. Going into clinical administration or a leadership and management role would be a natural step up, however, job opportunities can be limited in both areas. If a clinical role is more appealing, this essentially means stepping back and fully retraining.
The recent Darzi Report paints a more optimistic picture, where there is an emphasis on establishing better links between community and health, therefore a potential for more roles to develop within the current gap.
Measuring the impact of the service
Sarah acknowledges that there are still challenges when it comes to evidencing the impact of the service, despite the clear value patients derive from it.
There is no comprehensive system for tracking patient outcomes, and the team is continuing to work on capturing better, high-quality data to demonstrate the positive outcomes from their interventions, such as the increased uptake of health checks.
🎯TIP : Don't rush in, thinking you can change the world. Small things can truly make a massive difference in the world of care coordination.
For example, a frail, bed-bound patient suffering from loneliness throughout the day because her husband cannot sit comfortably to watch television upstairs. By making a home visit, the care coordinator identified this and arranged for the television (and the husband’s comfortable armchair) to be moved from the downstairs living room to the bedroom, allowing the couple to spend more time together.
This is a real-life example that has made a positive difference to the wellbeing of the patient, and which, unfortunately, cannot be easily evidenced in terms of data and outcome.
Our key takeaways
It’s fundamental that you have a means of capturing data effectively however we fully recognise the challenges of doing so within the current system.
There is also a challenge of securing long-term funding to sustain these roles and to develop care coordination services further.
The importance of having high trust across the network, and the ability to work collaboratively cannot be underestimated.
Lastly, it’s super important that we recognise the value of Care Coordinators and that we invest in supporting them, to allow them to flourish in their roles.
To view the webinar in full it can be seen here
We hope this helps!
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I'm Tara; I am the founder of THC Primary Care, an award-winning healthcare consultancy specialising in Primary Care Network Management and the host of the Business of Healthcare Podcast.
I have over 20 years of project management and business development experience across the private and public sectors, and I have supported over 200 PCNs by providing interim management, training and consultancy.
I have managed teams across multiple sites and countries; I have an MBA in Leadership and Management in Healthcare, I'm published in the London Journal of Primary Care, and I am the author of over 250 blogs.
I have 3 children. My eldest has Asthma, my middle child has a kidney condition called Nephrotic Syndrome, and my youngest daughter has Type 1 Diabetes, so outside of work, healthcare plays a huge role in my life.
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