Primary Care Network Frailty Care Co-ordinator

Job responsibilities

Job Description

Job Title: Primary Care Network Frailty Care Co-ordinator Accountable to: Partners & Visiting Team Lead Location:Designated GP Practices

Job Summary - A frailty care coordinator holistically supports patients with mild to severe frailty within the community. They work with patients to create a patient-centred care plan and provide access to support services within the area that are most appropriate for them. Working as part of a multi-disciplinary team you will support the delivery of patient care across the PCN aligned Care Homes and housebound patients. The post holder will provide appropriate care and support and will focus on individual patient needs and will ensure any changing needs are addressed. Signposting individuals in order that they may access appropriate support from other services as appropriate. Identification of patients living with frailty and pro-actively working with those patients to intervene before crisis. Ensure the PCN meets the DES specifications for frailty and Enhanced Health in Care Homes Administrative duties focus on providing coordination, a point of contact for both the home and clinical staff and ensuring there are robust process and pathways between Primary, Secondary and Community Care.

Job Responsibilities

To collaborate with Practices and the broader community care team to ensure that patients living with frailty receive appropriate interventions aimed at assisting them in maintaining as much independence as possible. To visit and support patients at their place of residence to assess any unmet health or care needs. To complete holistic person centred care planning. Where unmet are identified to completed relevant referrals into appropriate organisations. To attend the weekly ICC MDT meetings where appropriate. There will be an element of clinical assessment required such as venepuncture and observations (training will be provided).

This job description is not exhaustive. This is an evolving role and will be subject to evolution as required to meet the needs of patients and NHS contracts.

Key working relationships PCN Clinical Directors, PCN Operations Managers, Practice Managers, PCN colleagues including Social Prescribing teams, GP, nurses and other practice staff, GP Prescribing Lead, Community nurses and other healthcare professionals (e.g. OT, ICT, CPN, nursing home staff etc.), Community and hospital pharmacy teams, Community Health and Social Care Teams, ICC Teams, Care Organisations, Patients and carers, Community pharmacists, Practice Pharmacists, Other primary care health professionals, Third Sector Organisations

Duties and Responsibilities of the Post - The purpose of the role will be to support patients living with frailty, reviewing their care plans and ensuring they are supported to live well in their place of residence. To support the PCN practices to meet the requirements of the Enhanced Care in Care Homes, Personalised and Anticipatory Care model, this will include primary care support and some community based support. Proactively targeting patients identified as living with frailty. In partnership with their carers/relatives, carry out an holistic assessment which encompasses health and social care aspects of care. Conduct low level clinical screening such as dementia screening, blood pressure checks and venepuncture as directed by the lead health professional. (Where relevant training has been received) Falls risk assessments to be undertaken. Provide a care plan and refer as appropriate to other organisations or provide support as required to ensure patient is well supported. Act on communications from hospitals or community providers, ensuring care plans are updated in a timely manner. Act on incoming requests from patients, carers, care homes and other providers Have the ability to organise and prioritise own workload. Proactively support patients to take up vaccinations such as flu and covid and participate in the delivery of these. Work collaboratively with other care coordinators across the PCN to share best practice To participate in discussions about the direction of service developments and improvements. To participate in service audits and changes. To participate in appraisal processes and participate in CPD/ personal development plan. To pro-actively participate in mandatory training and in-service training

SKILLS, KNOWLEDGE AND APTITUDES

Essential

• Well-developed communication, negotiation, presentation and interpersonal skills.
• Ability to organise and prioritise workload and meet deadlines
• Ability to work independently and as part of a team.
• Ability to work accurately to deadlines.
• Leadership skills.
• Coaching skills.
• Organisational skills.
• Ability to adapt to change within working situations
• Able to maintain and develop professional relationships.
• Able to identify when advice needs to be sought, recognising
• personal limitations.
• Computer literate.

Desirable

• Reflective working
• Awareness of frailty and chronic conditions
• Knowledge of the ICC and third sector working.
• Understanding of role of patient advocate.
• Local area knowledge

Qualifications

Essential

• Qualifications
• ESSENTIAL - English and Maths to GCSE
• Grade C or above or equivalent.
• Or BTEC???/NVQ level
• education

Desirable

• DESIRABLE - NVQ or equivalent in
• administration / customer
• services / Health & Social Care

Experience

Essential

• Previous experience working
• with the general public.
• Evidence of good practice
• Working autonomously and as
• part of a team

Desirable

• Previous experience working
• with frail, older people.
• Experience of working in a
• health care setting.

OTHER REQUIREMENTS

Essential

• Current driving licence and access to own vehicle
• Ability to participate in 7 day working shift patterns

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.

Certificate of Sponsorship

Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).

From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).