Job summary
We are recruiting a Care Coordinator to play
a vital role in a brand new Frailty team within our developing PCN. We are looking for an experienced and highly organised Care
Coordinator to work with people living with moderate or severe
frailty and/or dementia to provide co-ordination and navigation of care and
support across health, care and support services. The role works closely with GPs, Practice
teams, Social Prescriber and wider PCN team to provide a personalised care
approach. The Care Coordinator will act
as a central point of contact to ensure appropriate support is made available
to people and their carers; enabling them to understand and manage their
condition and ensuring their changing needs are addressed.
You will be based in the
Forest of Dean (location to be agreed) and you must be prepared to work across
various locations in the Forest of Dean and occasionally may be required to
attend GDOCs offices in Gloucester.
The post holder will work closely
with other members of the Frailty team including the Frailty Practitioner and Frailty
Administrators.
Hours: Up to 30 hours per week
The closing date is 30th
November 2025
Main duties of the job
Support the Frailty
Practitioner with case identification using digital risk stratification
Use and maintain the
Personalised Proactive Whiteboard to enable coordination of care
Support Frailty
Practitioner to triage patients, complete comprehensive Geriatric Assessments
(CGA) and determine and monitor actions.
Ensure relevant
patients have a Personalised Care and support Plan (PCSP) and a ReSPECT form.
Coordinating the care
of each patient, ensuring close multi-agency and multi-professional working.
Ensure relevant
colleagues complete their agreed interventions listed in the PCSP, escalating
where necessary.
Regular review of
patients to ensure continuity of care
Support other members of the Frailty Team including
Practitioners and Administrators.
Provide a single point of contact for patients and provide
coordination and navigation across services.
Support coordination and delivery of MDTs.
Work collaboratively with GPs and other General Practice
Team Members
Update patient records including clinical coding
Through the PPW and other methods, maintain records of
referrals and interventions to enable monitoring and evaluation of the service
Please see job description and
Frailty Team Functions Overview documents for further information.
Frequent prolonged VDU use
About us
The Care Quality
Commission requires us to have a complete employment history from the age of
16, including explanations for any gaps in employment.
You will be required to be immunised in compliance with Green Book (link
attached) and NHS recommendations for your role (unless medically exempt),
including immunisations against Covid
West FOD PCN is hosted by G DOC LTD.
G DOC LTD is a unique, GP-owned organisation. All GP
surgeries in Gloucestershire are our shareholders. We operate with a
not-for-profit ethos, ensuring every decision and service is focused on
improving patient outcomes and reinvesting in local Primary Care across the
county.
We directly manage several GP surgeries in Gloucester
and the Forest of Dean, providing patient-centred care to more than 45,000
patients. We value continuity of care and practice teams are at the heart
of all we do. In addition to our surgeries, we deliver a range of countywide
commissioned services designed to improve access, increase capacity, or provide
specialist support. Our teams are committed to delivering sustainable,
high-quality primary care while fostering innovation and collaboration across
the local health system.
By joining us, you'll be part of an organisation that
puts people first supporting staff wellbeing, professional development, and a
collaborative culture. You'll benefit from the stability, support, and career
opportunities of a larger organisation, while still working in close-knit,
community-focused teams.
Job description
Job responsibilities
Case Identification
Support
the Frailty Practitioner as required to undertake digital risk stratification
Transpose data
onto the Personalised Proactive Whiteboard (PPW), ready to enable care
coordination
Holistic
Assessment
Support the Frailty
Practitioner to triage potential patients to determine who receives a
Comprehensive Geriatric Assessment (CGA)
Support the Frailty
Practitioner to determine what action to take with those patients who do not
receive a CGA, including ensuring actions are undertaken
Contribute to the completion
of CGAs as determined by the Frailty Practitioner, inputting the information
gleaned into a digital template
Personalised
Care and Support Planning
As determined by the Frailty
Practitioner
Ensure
each patient who has a CGA has a Personalised Care and Support Plan (PCSP) that
has been discussed and finalised with the patient and any carer/family; this
will help to manage their needs and achieve better health and wellbeing
outcomes
Ensure
a ReSPECT plan is completed for each patient who has a CGA
Coordinated
and Multi-Professional Working
Be responsible for
coordinating the care of each patient, ensuring close multi-agency and
multi-professional working, especially with the local Integrated Neighbourhood
Team(s), to facilitate delivery of each patients PCSP
Use and be fully responsible
for the care coordination function of the PPW as the method of managing and
coordinating the care for each patient
Be responsible for ensuring
relevant colleagues complete their agreed interventions listed in the PCSP,
escalating issues if required to the Frailty Practitioner
Continuity
of Care including Review
Be responsible for ensuring
each patient who has a CGA has their CGA/PCSP regularly reviewed (e.g. every
six months) according to need
Be responsible for ensuring
each patient who has a significant life event is offered a review of their
CGA/PCSP, e.g. when they have been admitted to hospital on a planned or
unplanned basis, or had a fall, or a close family bereavement
General
Alongside the Frailty
Practitioner, provide support to the Frailty Team Administrator as required.
Identify carers and help
them access services to support them, ensuring they are coded as a carer on the
GP clinical system if they are a patient at the Practice
Provide a single point of
contact to answer queries, make and manage appointments, and ensure that people
have good quality written or verbal information to help them make choices about
their care.
Assist people to access
self-management education courses, peer support, health coaching and other
interventions to enable them to better manage their health and wellbeing.
Provide co-ordination and
navigation across services, helping to ensure people and their carers receive a
joined-up service and the appropriate support from the right person at the
right time.
Work collaboratively with
GPs and other General Practice team members within the PCN to proactively
identify and manage a caseload, and where appropriate, refer back to other
health practitioners within the PCN.
Support the co-ordination
and delivery of multidisciplinary teams with the PCN, if required.
Identify people, using tools
such as the PPW, who may benefit from shared decision making and support PCN
staff and people to be more prepared to have shared decision-making
conversations
Explore and assist people to
access a personal health budget where appropriate and available.
Undertake clinical coding to
create reliable
patient records used for diagnosing accurately, planning treatment, and
ensuring patient safety.
Competently use clinical
systems and templates to capture, and report patient records.
Follow-up on communications
from out of hospital and in-patient services.
Through the PPW and other
methods, maintain records of referrals and interventions to enable monitoring
and evaluation of the service.
Contribute to risk and
impact assessments, monitoring and evaluation of the service
Work with
commissioners, Integrated Neighbourhood Team members and other agencies to
support and further develop the Care Coordinator role and the work of the wider
PCN Frailty Team
Other responsibilities
Applying PCN
policies, standards and guidance
Contributing
to the teaching and training of trainees, new employees and employees who are
undertaking training
Awareness of
and compliance with all relevant G DOC policies/guidelines for your role, e.g.
prescribing, confidentiality, data protection, health and safety
Contributing
to evaluation/audit and clinical standard setting within the organisation as
applicable to your role
Attending
training,meetings and other meetings and events organised by the Practices,
PCN, or other agencies such as the ICB
Contributing
to audits and written returns to ensure that the PCN meets quality standards
and receives the designated funding, as appropriate to your role
Please see full job description attached
Job description
Job responsibilities
Case Identification
Support
the Frailty Practitioner as required to undertake digital risk stratification
Transpose data
onto the Personalised Proactive Whiteboard (PPW), ready to enable care
coordination
Holistic
Assessment
Support the Frailty
Practitioner to triage potential patients to determine who receives a
Comprehensive Geriatric Assessment (CGA)
Support the Frailty
Practitioner to determine what action to take with those patients who do not
receive a CGA, including ensuring actions are undertaken
Contribute to the completion
of CGAs as determined by the Frailty Practitioner, inputting the information
gleaned into a digital template
Personalised
Care and Support Planning
As determined by the Frailty
Practitioner
Ensure
each patient who has a CGA has a Personalised Care and Support Plan (PCSP) that
has been discussed and finalised with the patient and any carer/family; this
will help to manage their needs and achieve better health and wellbeing
outcomes
Ensure
a ReSPECT plan is completed for each patient who has a CGA
Coordinated
and Multi-Professional Working
Be responsible for
coordinating the care of each patient, ensuring close multi-agency and
multi-professional working, especially with the local Integrated Neighbourhood
Team(s), to facilitate delivery of each patients PCSP
Use and be fully responsible
for the care coordination function of the PPW as the method of managing and
coordinating the care for each patient
Be responsible for ensuring
relevant colleagues complete their agreed interventions listed in the PCSP,
escalating issues if required to the Frailty Practitioner
Continuity
of Care including Review
Be responsible for ensuring
each patient who has a CGA has their CGA/PCSP regularly reviewed (e.g. every
six months) according to need
Be responsible for ensuring
each patient who has a significant life event is offered a review of their
CGA/PCSP, e.g. when they have been admitted to hospital on a planned or
unplanned basis, or had a fall, or a close family bereavement
General
Alongside the Frailty
Practitioner, provide support to the Frailty Team Administrator as required.
Identify carers and help
them access services to support them, ensuring they are coded as a carer on the
GP clinical system if they are a patient at the Practice
Provide a single point of
contact to answer queries, make and manage appointments, and ensure that people
have good quality written or verbal information to help them make choices about
their care.
Assist people to access
self-management education courses, peer support, health coaching and other
interventions to enable them to better manage their health and wellbeing.
Provide co-ordination and
navigation across services, helping to ensure people and their carers receive a
joined-up service and the appropriate support from the right person at the
right time.
Work collaboratively with
GPs and other General Practice team members within the PCN to proactively
identify and manage a caseload, and where appropriate, refer back to other
health practitioners within the PCN.
Support the co-ordination
and delivery of multidisciplinary teams with the PCN, if required.
Identify people, using tools
such as the PPW, who may benefit from shared decision making and support PCN
staff and people to be more prepared to have shared decision-making
conversations
Explore and assist people to
access a personal health budget where appropriate and available.
Undertake clinical coding to
create reliable
patient records used for diagnosing accurately, planning treatment, and
ensuring patient safety.
Competently use clinical
systems and templates to capture, and report patient records.
Follow-up on communications
from out of hospital and in-patient services.
Through the PPW and other
methods, maintain records of referrals and interventions to enable monitoring
and evaluation of the service.
Contribute to risk and
impact assessments, monitoring and evaluation of the service
Work with
commissioners, Integrated Neighbourhood Team members and other agencies to
support and further develop the Care Coordinator role and the work of the wider
PCN Frailty Team
Other responsibilities
Applying PCN
policies, standards and guidance
Contributing
to the teaching and training of trainees, new employees and employees who are
undertaking training
Awareness of
and compliance with all relevant G DOC policies/guidelines for your role, e.g.
prescribing, confidentiality, data protection, health and safety
Contributing
to evaluation/audit and clinical standard setting within the organisation as
applicable to your role
Attending
training,meetings and other meetings and events organised by the Practices,
PCN, or other agencies such as the ICB
Contributing
to audits and written returns to ensure that the PCN meets quality standards
and receives the designated funding, as appropriate to your role
Please see full job description attached
Person Specification
Qualifications
Essential
- GCSE grade 4/C or above in maths & English, or equivalent
Personal qualities
Essential
- Clear, polite telephone manner
- Polite and confident
- Flexible and cooperative, motivated
- High levels of integrity and loyalty
- Demonstrates empathy, respect, and kindness in all interactions
- Collaborative and able to work effectively across disciplines and organisations to deliver joined-up care
- Person centred (Prioritises the individuals needs, preferences, and dignity)
- Innovative: Seeks out and applies evidence-based practices and new models of care
- Promotes equality, diversity, and cultural competence in care delivery
- Able to use own initiative but also know when to seek assistance
- Ability to work under pressure
- Willingness to embrace change and contribute to ongoing improvements within the service
- Takes responsibility for tasks and service outcomes, ensuring high standards in service delivery
- Engages in continuous professional development and reflective practice
Knowledge and Skills
Essential
- Excellent communication (written and oral) and interpersonal skills, comfortable and confident in communicating with a wide variety of people and organisations
- Strong IT skills
- Competent in using Microsoft office software, including word processing and spreadsheets
- If not already competent in SystmOne, willing and able to undertake training and develop competency
- Ability to manage sensitive information with discretion and adhere to confidentiality requirements
- Proactive and problem-solving skills and the ability to work under pressure in a fast-paced environment
- Ability to follow policy and procedure
- Effective time management (organising and planning)
- Ability to work independently, as well as part of a team
- Strong organisational skills including planning, prioritising and record keeping
- Understanding of personalised care, wider determinants of health and equality, diversity and inclusion
- Ability to provide non-judgemental, culturally sensitive support using health coaching approaches
- Understanding of the holistic needs of people living with frailty and long-term conditions particularly in relation to promoting their independence
- Able to support data collection and use of tools to measure impact of services
- Knowledge of healthcare administration and familiarity with medical terminology
Desirable
- Competent in use of SystmOne
Experience
Essential
- Experience of working in an administrative role
Desirable
- Experience in an NHS or other healthcare setting
- Broad experience of General Practice
Person Specification
Qualifications
Essential
- GCSE grade 4/C or above in maths & English, or equivalent
Personal qualities
Essential
- Clear, polite telephone manner
- Polite and confident
- Flexible and cooperative, motivated
- High levels of integrity and loyalty
- Demonstrates empathy, respect, and kindness in all interactions
- Collaborative and able to work effectively across disciplines and organisations to deliver joined-up care
- Person centred (Prioritises the individuals needs, preferences, and dignity)
- Innovative: Seeks out and applies evidence-based practices and new models of care
- Promotes equality, diversity, and cultural competence in care delivery
- Able to use own initiative but also know when to seek assistance
- Ability to work under pressure
- Willingness to embrace change and contribute to ongoing improvements within the service
- Takes responsibility for tasks and service outcomes, ensuring high standards in service delivery
- Engages in continuous professional development and reflective practice
Knowledge and Skills
Essential
- Excellent communication (written and oral) and interpersonal skills, comfortable and confident in communicating with a wide variety of people and organisations
- Strong IT skills
- Competent in using Microsoft office software, including word processing and spreadsheets
- If not already competent in SystmOne, willing and able to undertake training and develop competency
- Ability to manage sensitive information with discretion and adhere to confidentiality requirements
- Proactive and problem-solving skills and the ability to work under pressure in a fast-paced environment
- Ability to follow policy and procedure
- Effective time management (organising and planning)
- Ability to work independently, as well as part of a team
- Strong organisational skills including planning, prioritising and record keeping
- Understanding of personalised care, wider determinants of health and equality, diversity and inclusion
- Ability to provide non-judgemental, culturally sensitive support using health coaching approaches
- Understanding of the holistic needs of people living with frailty and long-term conditions particularly in relation to promoting their independence
- Able to support data collection and use of tools to measure impact of services
- Knowledge of healthcare administration and familiarity with medical terminology
Desirable
- Competent in use of SystmOne
Experience
Essential
- Experience of working in an administrative role
Desirable
- Experience in an NHS or other healthcare setting
- Broad experience of General Practice
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.