Care Coordinator


Having many health conditions or seeking support for a mental health condition can mean that you see a variety of health and social care professionals. A care coordinator wants to make sure individuals have the fastest and best-quality service with continuity.

An integrated approach – the importance of team working and care coordination. Integration of health and social care level is critical in delivering effective care planning. Multidisciplinary team working is crucial to ensure an integrated approach to personalised care planning, especially for those with complex care needs that are more likely to require care from a range of different agencies/health and social care staff. Collaborative working is also vital to ensure that all staff can deliver high quality care.

When is care coordination appropriate?

  • Think about the trigger events that could initiate the appointment of a care coordinator. These could include A high number of different staff groups/ agencies involved in supporting the individual.
  • Where intervention will be required over a long period of time
  • When the level of need increases and multiple services are required
  • Experiencing a high number of unplanned emergency admissions
  • On discharge from hospital.
  • Have chronic health conditions and/or complex healthcare needs.
  • Would benefit from care coordination and self-management support.
  • Palliative care/ End of Life.

Care Co-ordinators will:

  • Proactively identify and work with people in need of additional support.
  • Provide coordination and navigation of care and support across health and care services.
  • Act as a central point of contact.
  • Work alongside the social prescribing link workers and health and wellbeing coaches to enrich the skill mix of primary care teams.
  • Will liaise with all services to ensure a joined up working process.
  • Review patients’ needs and help them access community services.
  • Mapping the individuals needs and aligning this to community specialist services.
  • Work with social prescribing link workers health, wellbeing coaches and other professionals where appropriate to provide continuity in care.
  • Providing time, capacity and expertise to support people in preparing for or following-up clinical conversations they have.
  • Providing access to information and resources to help build knowledge, confidence and skills to manage own health and empower the Individual.
  • Liaising with other professionals on a need to know basis.
  • Clearly mapping out your story and your needs.
  • Providing links to information that can help with an individual’s health journey.

Care coordination ends when there is agreement from all concerned that the individual’s needs are stable and care planning is functioning well.