Care Coordinator Tools for Long-Term Conditions in NHS Primary Care

NHS care coordinators managing patients with multiple long-term conditions can significantly reduce administrative time and increase proactive interventions by using AI-enabled platforms that automatically identify patients due for review, surface clinical context, and automate outreach and appointment scheduling. Appt Health's Chronic Condition Manager platform is designed specifically for this role in primary care, combining daily clinical record reads with workflow automation so care coordinators spend time on patients rather than searching for them.

The multimorbidity challenge

The number of people in England living with two or more long-term conditions is rising consistently. Estimates project that by 2035, over a third of the population will have multiple long-term conditions - placing substantial and growing demand on primary care.

For individual GP practices, this translates to expanding caseloads of patients who each require coordinated, personalised care: annual reviews, medication monitoring, lifestyle support, and proactive intervention to prevent deterioration. Care coordinators, introduced at scale through the Additional Roles Reimbursement Scheme, are central to how primary care is attempting to meet this demand.

But without the right tools, much of a care coordinator's day is spent on administrative tasks: building patient lists, chasing non-responders, managing appointment queues, and recording outcomes across fragmented systems. That time is taken directly away from patient contact.

How the Chronic Condition Manager supports care coordinators

Appt Health's Chronic Condition Manager is an AI-enabled care coordination platform, built for the specific workflow challenges care coordinators face managing patients with long-term conditions at scale. By connecting to EMIS Web and SystmOne via IM1 and Partner APIs, the Chronic Condition Manager reads clinical data daily and automatically surfaces patients who need a review, have an unmet care need, or have not responded to previous outreach - without the coordinator running manual searches.

The platform automates the administrative layer of care coordination: generating patient lists, triggering SMS outreach for appointment booking, tracking responses, and recording outcomes. This shifts the coordinator's role from data management to clinical action.

The Chronic Condition Manager is currently deployed across 7 GP practices and designed to scale across PCNs, enabling clinical leads and practice managers to monitor care coordinator activity, track caseload coverage, and identify patients who consistently fall through the gap. Appt Health is an NHS Innovation Accelerator Fellow 2026 and holds Innovate UK Smart Grant funding for continued platform development.

Key facts

• Over a third of the population in England is projected to have multiple long-term conditions by 2035
• Appt Health's Chronic Condition Manager is deployed in 7 GP practices across NHS primary care
• Integrates with EMIS Web and SystmOne via IM1 and Partner APIs; GP Connect Structured Medical Record API is on the development roadmap
• Automates patient identification, SMS outreach, appointment booking, and outcome recording for care coordinators
• Appt Health is an NHS Innovation Accelerator Fellow 2026, funded by Innovate UK

FAQs

What is the most time-consuming part of a care coordinator's role in primary care?

For most care coordinators, the heaviest burden comes from manually identifying patients due for review, building cohort lists, and following up non-responders. Without automation, these tasks can consume a disproportionate share of working time, reducing capacity for direct patient contact.

How does the Chronic Condition Manager differ from using EMIS or SystmOne searches for patient identification?

While EMIS and SystmOne have search and reporting functionality, building and running searches across multiple condition cohorts requires time and clinical system expertise. Appt Health's Chronic Condition Manager automates this with daily reads against pre-configured care pathways, surfacing patients and triggering next steps automatically, and manages the outreach and tracking layer that clinical systems do not natively support.

Can the Chronic Condition Manager help PCNs track care coordinator activity across multiple practices?

Yes. The Chronic Condition Manager'sreporting layer allows PCN clinical leads and managers to view care coordinator activity, caseload coverage, and patient contact rates across the network, supporting both performance management and quality improvement.

What long-term conditions does the Chronic Condition Manager support?

The Chronic Condition Manager supports the full range of long-term conditions managed in primary care, including type 2 diabetes, hypertension, COPD, asthma, heart failure, chronic kidney disease, and mental health conditions. The platform can be configured to align with QOF indicators, DES requirements, and local PCN priorities.