Care Coordination Service  

Care Coordination Service 

About the service

Often patients with multiple health problems find themselves working with different professionals for different bits of their health and social care. The professionals often focus on just their area of expertise rather than the whole person. The Care Coordination Service plans to change that. It aims to make sure that patients with one or more long-term condition (like diabetes, mobility issues, hearing loss, heart conditions, cancer, learning disabilities etc.) have a well-informed team of people looking after their whole health and wellbeing. This is done by assigning them a Care Coordinator.

A Care Coordinator works with all the people involved in caring for someone and helping them remain independent at home. They coordinate that team of professionals in a way that works well.

The service is for:

  • People aged over 18, with one or more long term health condition.

The Primary Care Network care team could also include the patient’s GP, specialists for particular health conditions, social workers, friends, family, carers and local community and mental health services.

Together with the patient they design and follow a shared care plan.

Telephone number:  020 8967 5400 

For more information contact the Care Coordination Team on

Service Manager/Manager/Lead

Rubyna Krishan – Team Manager

Rosemary Gifford – Service Manager for Locality Services, West London NHS Trust

Clinical Director 

Dr Christopher Hilton

Clinical Director for Integrated Care Services

Ealing Community Partners (West London NHS Trust)

Information about your care 

We provide you with a Care Coordinator who will work with members of your Primary Care Network team to help you better to plan your care.

Where we provide your care

We provide care at GP locations across Ealing’s 8 Primary Care Networks.


Patients may be referred for care coordination by their GP, or other healthcare professionals within Ealing Community Partners.

Sometimes we are aware from information available to us that people’s care needs may be increasing (such as many visits to the hospital, or calls to crisis lines) and if we identify this, we may contact you to ask if you for your consent for us to become involved.

Contact us

If you have any questions about Ealing Community Partners or your care please call 

0300 12345 44

Ealing Community Partners: NHS, Ealing Council, voluntary & specialist providers working together to deliver health & social care for the people of Ealing  

We’re changing the way some of our services are delivered during the coronavirus (Covid-19) public health emergency.Find out more
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