Job summary
North and South Gloucester Primary Care Network seek a dedicated Frailty Care Coordinator to join our growing Living Well Team. This exciting new role offers a unique opportunity to make a real difference in the lives of the ageing population within our community.
As a key member of the PCN, you will collaborate closely with our GP practices, the Living Well Team and a wide range of health, social care and community partners. This position will evolve alongside our Team, allowing you to play a vital role in shaping the future direction of the team.
You will be
the main point of contact for the team, triaging referrals from our
practices and ensuring these are signposted appropriately. The organisation of Multi-Disciplinary Team meetings, including accurate record-keeping and
follow-up on agreed actions, will be a key responsibility. You will also manage your own small caseload,
visiting patients at home to complete and review Personalised Care and Support Plans, Me at my Best, and What Matters to Me forms.
We are
looking for a confident communicator with exceptional interpersonal skills, a
strong sense of organisation, and a patient, empathetic approach. Previous experience of working in a
patient-facing health, social care or related support role, either in a
clinical or non-clinical role, is essential.
The role is offered for between 30 to 37.5 hours per week, initially for a fixed term of 12 months with a view to permanency subject to confirmation of future funding.
Main duties of the job
Act as the focal point of contact for the Team.
Triage/screen incoming referrals and signpost appropriately.
Provide coordination and navigation for people and their carers across health and care services, alongside working closely with our Living Well Team (Social Prescribing Link Works, Frailty Nurses and Care Coordinators) and all members of our primary care teams.
With the support of the Practices and Network proactively identify a cohort of people in need of anticipatory coordinated support, using local knowledge and population health intelligence
Manage the Team shared email
inbox, ensuring that all messages are dealt with efficiently and any necessary
actions are assigned appropriately.
Manage the Team shared email inbox, ensuring tasks are triaged appropriately.
Lead on the organisation, coordination and delivery of Multi-Disciplinary Team meetings within the Network, including producing the agenda and taking minutes, recording and following up actions within defined timescales agreed during the meeting.
Improve continuity of care by acting as a point of contact for people, families and professionals.
Identify and manage own caseload of patients, carrying out home visits to complete/review Personalised Care and Support Plans, Me at my Best and What Matters to Me forms.
Ensure people have good quality information to help them make choices about their care and structure conversations using a coaching approach.
About us
North & South Gloucester (NSG) Primary Care Network (PCN) consists of five surgeries located around Gloucester The Alney Practice, Brockworth Surgery, Churchdown Surgery, Hucclecote Surgery and Longlevens Surgery.We are a growing PCN with over 58,000 patients and a PCN staff of over 40.We are passionate about developing and delivering excellent quality local services to meet the needs of our communities. We work closely together with a wide range of local providers, including acute trusts, social care, the voluntary and community sector, and patient participation groups to offer proactive, personalised, preventative, and co-ordinated health and social care to our local population.
Job description
Job responsibilities
This
role will operate within the Frailty Team which forms part of our wider Living
Well Team made up of Frailty Nurses, Social Prescribing Link Workers, Health
and Wellbeing Coach and Care Coordinators. This is a new role for our network,
expanding our Frailty Team to address the needs of our population.
Job
Description
The Frailty Care Coordinator will play a key role within our PCN
working closely with our GP practice teams, our PCN Living Well Team and wider
health and social care and community colleagues. They will act as the main point of contact for the
Team, triaging incoming referrals from our member practices and signposting
appropriately. They will be responsible
for setting up and co-ordinating our Multi-Disciplinary Team meetings recording
and following up on agreed actions. They
will be involved with risk stratification, data searches, monitoring and
evaluation of services.
The Frailty Care Coordinator will also identify and
manage their own caseload of patients, carrying out home visits to complete and
review Personalised Care and Support Plans, Me at my Best and What Matters
to Me.
The key responsibilities of the role
are outlined below:
-
Act as the focal point of contact for the
Team.
-
Triage/screen incoming referrals and signpost
appropriately.
-
Provide coordination and
navigation for people and their carers across health and care services,
alongside working closely with our Living Well Team (Social Prescribing Link
Workers, Frailty Nurses and Care Coordinators) and all members of our primary
care teams.
-
With the support of the Practice and Network
proactively identify a cohort of people in need of anticipatory coordinated
support, using local knowledge and population health intelligence.
-
Manage the Team shared email
inbox, ensuring that all messages are dealt with efficiently and any necessary
actions are assigned appropriately.
-
Manage the Team Task inbox
ensuring tasks are triaged appropriately.
-
Lead on the organisation, co-ordination,
and delivery of MDTs within the PCN including producing the agenda and taking
minutes, recording and following up actions within defined timescales agreed
during the meeting.
-
Improve continuity of care by acting as a
point of contact for people, families and professionals.
-
Identify and manage their own caseload of patients,
carrying out home visits to complete/review Personalised Care and Support Plans,
What Matters to Me and Me at my Best Forms.
-
Ensure that people have good quality
information to help them make choices about their care and structure
conversations using a coaching approach.
-
Provide
time, capacity and expertise to support people in preparing for or following-up
on clinical conversations with health professionals.
-
Work with members of the primary care teams to
develop and implement data collection systems that will provide accurate and
timely data to monitor and evaluate services.
-
Raise awareness within the PCN to shared decision making and decision
support tools.
Job description
Job responsibilities
This
role will operate within the Frailty Team which forms part of our wider Living
Well Team made up of Frailty Nurses, Social Prescribing Link Workers, Health
and Wellbeing Coach and Care Coordinators. This is a new role for our network,
expanding our Frailty Team to address the needs of our population.
Job
Description
The Frailty Care Coordinator will play a key role within our PCN
working closely with our GP practice teams, our PCN Living Well Team and wider
health and social care and community colleagues. They will act as the main point of contact for the
Team, triaging incoming referrals from our member practices and signposting
appropriately. They will be responsible
for setting up and co-ordinating our Multi-Disciplinary Team meetings recording
and following up on agreed actions. They
will be involved with risk stratification, data searches, monitoring and
evaluation of services.
The Frailty Care Coordinator will also identify and
manage their own caseload of patients, carrying out home visits to complete and
review Personalised Care and Support Plans, Me at my Best and What Matters
to Me.
The key responsibilities of the role
are outlined below:
-
Act as the focal point of contact for the
Team.
-
Triage/screen incoming referrals and signpost
appropriately.
-
Provide coordination and
navigation for people and their carers across health and care services,
alongside working closely with our Living Well Team (Social Prescribing Link
Workers, Frailty Nurses and Care Coordinators) and all members of our primary
care teams.
-
With the support of the Practice and Network
proactively identify a cohort of people in need of anticipatory coordinated
support, using local knowledge and population health intelligence.
-
Manage the Team shared email
inbox, ensuring that all messages are dealt with efficiently and any necessary
actions are assigned appropriately.
-
Manage the Team Task inbox
ensuring tasks are triaged appropriately.
-
Lead on the organisation, co-ordination,
and delivery of MDTs within the PCN including producing the agenda and taking
minutes, recording and following up actions within defined timescales agreed
during the meeting.
-
Improve continuity of care by acting as a
point of contact for people, families and professionals.
-
Identify and manage their own caseload of patients,
carrying out home visits to complete/review Personalised Care and Support Plans,
What Matters to Me and Me at my Best Forms.
-
Ensure that people have good quality
information to help them make choices about their care and structure
conversations using a coaching approach.
-
Provide
time, capacity and expertise to support people in preparing for or following-up
on clinical conversations with health professionals.
-
Work with members of the primary care teams to
develop and implement data collection systems that will provide accurate and
timely data to monitor and evaluate services.
-
Raise awareness within the PCN to shared decision making and decision
support tools.
Person Specification
Qualifications
Essential
- Good standard of education with 5 C/GCSE's or equivalent.
- Good IT skills, especially a working knowledge of MS Office (Word, Excel, Powerpoint, Outlook).
- Commitment to continuing professional development, including the Personalised Care Institute course(s).
- Full UK Driving Licence.
Desirable
- Further education qualifications or Degree level education.
- Training in health coaching/motivational interviewing or equivalent.
Communication
Essential
- Excellent interpersonal and communication skills.
- Ability and confidence to handle difficult conversations.
- Ability to structure conversations using a coaching approach based on what matters to the person.
- Be able to talk to a wide range of professionals appropriately.
- Ability to nurture key relationships and maintaining networks.
Experience
Essential
- Experience of working in the NHS (preferably in Primary Care) or for a private care provider. This could be in a clinical or non-clinical role.
- Experience in working and communicating with multiple stakeholders.
Desirable
- Experience and understanding of evaluating and measuring the performance of health services.
- Experience in using clinical IT systems, in particular EMIS or SystmOne.
- A good understanding of the health and social care environment and roles and responsibilities within it.
- Knowledge of existing referral pathways to local health, social care and voluntary organisations.
Skills and Attributes
Essential
- Ability to work independently and proactively.
- Be able to manage multiple demands and prioritise appropriately.
- Ability to seek solutions and solve problems using your own initiative.
- Adaptability, flexibility and ability to cope with uncertainty and change.
- Be able to focus in a busy work environment.
- Demonstrate a strong desire to improve performance and make a difference by focusing on goals.
- Work in confidential manner and maintain trust of colleagues and patients.
- Excellent time keeping
Person Specification
Qualifications
Essential
- Good standard of education with 5 C/GCSE's or equivalent.
- Good IT skills, especially a working knowledge of MS Office (Word, Excel, Powerpoint, Outlook).
- Commitment to continuing professional development, including the Personalised Care Institute course(s).
- Full UK Driving Licence.
Desirable
- Further education qualifications or Degree level education.
- Training in health coaching/motivational interviewing or equivalent.
Communication
Essential
- Excellent interpersonal and communication skills.
- Ability and confidence to handle difficult conversations.
- Ability to structure conversations using a coaching approach based on what matters to the person.
- Be able to talk to a wide range of professionals appropriately.
- Ability to nurture key relationships and maintaining networks.
Experience
Essential
- Experience of working in the NHS (preferably in Primary Care) or for a private care provider. This could be in a clinical or non-clinical role.
- Experience in working and communicating with multiple stakeholders.
Desirable
- Experience and understanding of evaluating and measuring the performance of health services.
- Experience in using clinical IT systems, in particular EMIS or SystmOne.
- A good understanding of the health and social care environment and roles and responsibilities within it.
- Knowledge of existing referral pathways to local health, social care and voluntary organisations.
Skills and Attributes
Essential
- Ability to work independently and proactively.
- Be able to manage multiple demands and prioritise appropriately.
- Ability to seek solutions and solve problems using your own initiative.
- Adaptability, flexibility and ability to cope with uncertainty and change.
- Be able to focus in a busy work environment.
- Demonstrate a strong desire to improve performance and make a difference by focusing on goals.
- Work in confidential manner and maintain trust of colleagues and patients.
- Excellent time keeping
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.
