Tools and resources

Tailored resource: The named care coordinator role from the perspective of older people

Named care coordinator: the role

Named care coordinator: the role

An experienced and knowledgeable person, who can communicate and navigate within a complex system of care and support

The older people who took part in the focus groups welcomed the recommendations around the named care coordinator role but felt that is a very challenging one, with many different functions. They thought about what the role should cover, if it is to make a real difference to their lives, and suggested 3 main areas.

Preventative care and support

People felt that the named care coordinator had a crucial role to play in helping individuals stay as well as possible. They emphasised the importance of looking beyond the list of conditions to see the whole person, and of identifying and making use of the person's own network of support. This includes valuing the expertise of the next of kin, carer or friend. The participants also identified several things the named care coordinator could do to help keep the person well and avoid unnecessary hospital admissions:

  • Support the carer, and recognise their own needs and health conditions (see recommendation 1.1.4; section 1.3).

  • Understand health conditions and when symptoms need investigating (see recommendation 1.7.2).

  • Notice changes and act upon them to help avoid crises (see recommendation 1.7.2).

  • Share knowledge of health conditions and medication to enable self-management of long-term conditions and control over your own life (see recommendations 1.2.5–7, 1.2.11, 1.5.10–12).

  • Understand the impact of loneliness and isolation (see recommendations 1.6.1–4).

  • Enable change, balancing different opinions in the best interests of the person, and presenting the options available.

  • Understand the Mental Capacity Act, judgements about capacity and best interests decisions.

Planning and recording

The focus group participants highlighted care planning as a key aspect of the named care coordinator role, but emphasised that the care plan must be owned by the person. They suggested the following steps would help with this:

  • Develop all care plans in partnership with the person and their carer (see recommendations 1.2.2; 1.2.4–5, 1.2.9).

  • Ensure the person knows the plan for their care and support, signs their agreement and receives a copy (see recommendations 1.2.3).

  • Make sure other team members are aware of and understand the care plan (see recommendations 1.2.1, 1.2.8).

They also wanted to see the idea of forward planning taken further, and felt that the named care coordinator would be well placed to talk through some of the changes and crises that might occur and help the person to plan what they would want to happen in each situation. This would include advance planning for end of life care.

Working in partnership

Participants said that the ability of the named care coordinator to form effective working relationships with others in the health and social care system is absolutely crucial. They suggested that a helpful starting point for this is to take the time to communicate the role to other professionals, and to understand the role of others. This will help build influence and enable them to provide more effective support. Relationships with GPs, practice nurses, practice managers and pharmacists were felt to be particularly important. Participants also emphasised that a named care coordinator needs:

  • Good knowledge of other services and professionals and how to contact them, including specialist care that may be out of the area (see recommendations 1.1.2, 1.2.1, 1.5.12).

  • Thorough knowledge of the local system and support services available from health, social care and the voluntary sector (see recommendations 1.1.3, 1.5.4–5, 1.5.11, 1.6.4).

  • Good relationships with carers and providers, and a willingness to offer advice and guidance (see recommendations 1.1.4, 1.3.4).


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