Health & Wellbeing Coach (Frailty)

Job description

Job responsibilities

Clinical and Functional Skills

• Undertake comprehensive holistic assessments that are typically 60 to 90 minutes, exploring physical emotional social and environmental needs

• Manage a defined caseload from each practice plus new referrals generated from triage lists frailty registers and LCS Falls & Fractures data

• Perform blood pressure checks and venepuncture where trained and delegated

• Carry out falls risk assessments and co-develop care plans in collaboration with GPs and advanced clinical practitioners

• Implement digital monitoring tools to support independence mobility and wellbeing

• Educate and empower patients to recognise early signs of deterioration or mobility changes preventing crisis episodes and hospital admissions

• Contribute to proactive health screening and lifestyle interventions including bone health hydration nutrition and physical activity promotion

Holistic Wellbeing and Coaching

• Provide person centred health coaching to support self management goal setting and positive behaviour change

• Address key wellbeing determinants including nutrition hydration home safety mental wellbeing social isolation and financial security

• Initiate advance care planning discussions and promote the use of tools to record preferences and wishes

• Use motivational tools to encourage patients to visualise progress and goals

• Signpost or refer patients to appropriate internal or external services including social prescribers dementia support welfare advice community groups podiatry or dietetics

• Facilitate group coaching sessions and community based workshops on healthy ageing falls prevention resilience building and physical activity

• Encourage peer to peer support networks among older adults promoting social connectedness and shared learning

• Actively contribute to digital inclusion supporting patients and carers to use technology for health monitoring appointments and social connection

• Embed the Healthy Futures ethos by focusing on supporting independence hope and purpose in later life

• Provide support to patients on the gold standards framework register contributing to proactive end of life care planning

Care Home and Community Support

• Provide proactive input to local care homes focusing on falls prevention mobility and wellbeing reviews

• Review care plans conduct environmental safety checks and ensure appropriate equipment provision

• Strengthen communication and shared learning between care homes community services and primary care network clinicians

• Support staff training or awareness sessions in care homes around hydration nutrition and recognising early signs of frailty or infection

• Develop links with voluntary and community groups to offer outreach wellbeing sessions in community venues such as libraries leisure centres or sheltered housing

• Champion small sustainable behaviour changes that help residents maintain mobility and purpose aligned with the Healthy Futures prevention first approach

Collaborative and System Working

• Work as an integral member of the primary care network multidisciplinary team alongside GPs advanced clinical practitioners nurses social prescribers and care coordinators

• Collaborate with secondary care local authority and voluntary sector organisations to ensure seamless support and continuity of care

• Contribute to the development of frailty pathways population health initiatives and service evaluation within the primary care network

• Maintain accurate and timely documentation using approved clinical systems

• Participate in Healthy Futures working groups and contribute to primary care network wide initiatives such as active ageing weeks health promotion campaigns or targeted outreach in identified neighbourhoods

• Act as a community connector strengthening relationships between health care and community assets to build resilience and reduce dependency on clinical services

• Share learning and insight across practices to support proactive care planning digital innovation and continuous improvement

Contribution to Healthy Futures Programme

• Deliver proactive Healthy Futures health checks for adults covering cardiovascular cognitive and frailty domains in both GP practices and community venues

• Undertake and record baseline measures such as blood pressure BMI mobility tests mood and lifestyle indicators escalating clinical findings as appropriate

• Support early detection of cardiovascular risk frailty dementia and falls through structured screening tools

• Provide lifestyle advice and motivational coaching to empower patients to make sustainable behaviour changes promoting independence and self management

• Participate in community outreach to engage older adults who rarely access primary care tackling social isolation and health inequalities

• Contribute to population level risk stratification identifying low moderate and high risk categories and ensuring appropriate follow up or GP referral

• Collaborate with health care assistants nurses pharmacists social prescribers and the wider multidisciplinary team to ensure joined up delivery of Healthy Futures interventions

• Support delivery of Healthy Ageing Clinics within practices and community settings ensuring every patient receives a person centred holistic experience

• Capture outcomes patient feedback and activity data aligned to Healthy Futures key performance indicators including completion rates referral outcomes and patient satisfaction measures

• Contribute to service evaluation continuous improvement and scaling of Healthy Futures activities across the primary care network

• Act as an ambassador for prevention and proactive care promoting the Healthy Futures vision of living well for longer across all primary care network programmes

Professional Development and Governance

• Work under the supervision of the primary care network operations manager and clinical director with clinical guidance from the advanced clinical practitioner team

• Participate in regular supervision reflective practice and annual appraisal

• Undertake relevant continuing professional development in frailty health coaching and personalised care

• Comply with all governance safeguarding confidentiality and data protection requirements

• Actively contribute to primary care network quality improvement and service evaluation processes

Performance and Outcomes

• Support the primary care network in developing measurable outcomes for frailty work including falls reduction improved wellbeing and enhanced patient experience

• Capture and share qualitative outcomes patient stories and feedback to evidence impact

• Contribute to the primary care network population health management and personalised care objectives

Person Specification

Experience

Essential

• Experience in healthcare, primary care, community or voluntary sector roles supporting older or vulnerable adults
• Experience conducting holistic assessments and developing individual care or well-being plans
• Experience of multidisciplinary team working
• Experience supporting patients to set and achieve personal goals

Desirable

• Experience within a Primary Care Network or NHS frailty programme
• Experience working in care homes or with housebound patients
• Experience in service evaluation, QI or audit

Qualifications

Essential

• GCSE or equivalent English and Maths Grade C/4 or above
• Accredited Health & Wellbeing Coach qualification or willingness to complete within 12 months
• Evidence of training in health coaching, motivational interviewing or behaviour change
• Full UK driving licence and access to a vehicle for home and care home visits

Desirable

• Additional training in frailty, falls prevention, dementia care or occupational therapy assistant skills
• Digital health tools or telehealth training

Knowledge / Skills / Attributes

Essential

• Excellent communication and interpersonal skills
• Ability to motivate, coach and empower patients
• Strong organisational and time management skills; able to manage own caseload
• IT literacy - Microsoft Office, EMIS/SystmOne or similar systems
• Understanding of frailty, ageing, falls risk and social determinants of health
• Awareness of safeguarding and confidentiality principles

Desirable

• Knowledge of the Rockwood Frailty Scale, Advance Care Planning and NHS Personalised Care frameworks
• Experience using digital health or remote monitoring devices
• Familiarity with local community and voluntary sector resources

Personal qualities

Essential

• Compassionate, patient-centred and non-judgemental
• Proactive and self-motivated, with the ability to work independently and collaboratively
• Adaptable to evolving PCN and service priorities
• Commitment to professional growth and PCN values

Desirable

• Ability to contribute to service innovation, training or peer support

Experience

Essential

• Experience in healthcare, primary care, community or voluntary sector roles supporting older or vulnerable adults
• Experience conducting holistic assessments and developing individual care or well-being plans
• Experience of multidisciplinary team working
• Experience supporting patients to set and achieve personal goals

Desirable

• Experience within a Primary Care Network or NHS frailty programme
• Experience working in care homes or with housebound patients
• Experience in service evaluation, QI or audit

Additional information

Essential

• Full-time (37.5 hours per week).
• The role requires flexibility across all Bramhall & Cheadle Hulme PCN practices and care home settings.
• The post is subject to an enhanced DBS check.
• The job description and person specification will be reviewed annually to reflect service development and PCN priorities.

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.

Employer details

Employer name

Bramhall and Cheadle Hulme Primary Care Network

Address

Cheadle Hulme Medical Group

11 Ladybridge Road

Stockport

SK8 5LL

Employer's website

https://www.cheadlehulmeandbridgehouse.nhs.uk (Opens in a new tab)