PCN Frailty Care Coordinator

Job description

Job responsibilities

As a Care Coordinator focused on frailty, you will work as a key part of the PCN multi-disciplinary team. You will be the key link to the people whose care you are supporting, operating as a go to person to ensure that their care is seamless. You will be working as an advocate for patients who are struggling with their declining health. Care coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.

You will work closely with the Clinical Leads and other primary care professionals within Worcester City PCN to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed.

This will include achieving and exploring all options of support, assisting them to access services and identify any support they require. All patients on your caseload will receive a personalised care and support plan.

As an individual you will liaise with PCN Clinical Leads, GP Practice staff, Social Prescriber Link Workers, Clinical Pharmacists, Paramedics, Pharmacy Technicians and other professionals where appropriate.

Key Duties & Responsibilities:

Care Coordinators will:

• Provide coordination and navigation for people and their carers across health and care services, working closely with primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support.
• Work sensitively with people, their families and carers to improve their understanding of the patients condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
• Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care.
• To be able to manage a patients needs appropriately documenting all consultations within the patients notes.
• Listen to patients needs and help to manage their needs through answering queries and sign posting to the relevant services.
• Contact and organise clinical reviews for all patients with a new diagnosis or declining health with a GP/ACP/paramedic where appropriate.
• Liaise with appropriate GPs and professionals when appropriate.
• Build effective relationships with each practice and its staff.
• To run weekly clinical system searches for frailty patients contacting the patient to arrange appointments.
• Contribute to increasing performance of NHS contracts
• Contribute to the evaluation of the service, collate and input timely data and suggest/implement service improvements.
• Keeping up to date with National/Local Frailty Strategies.
• Ability to work within a team and independently.
• Undertake any other duties deemed appropriate by the PCN Manager and clinical teams.
• Complete annual mandatory training as required.
• Enrol as a member of the Personalised Care Institute to receive up to date training and the opportunity to join webinars.
• Participation in an annual individual performance review, including taking own responsibility for maintaining record of own personal record.

Provide personalised support:

• Work with the patient, their families and carers and consider how they can all be supported by services available to them.
• Bring together a persons identified care needs and explore their options to meet these within a simple coproduced personalised care and support plan, including what they can expect from the groups, activities and services they are being connected to and what the person can do for themselves to improve their health and wellbeing.
• Seek advice and support from the Clinical Leads and/or identified individual(s) to discuss patient-related concerns (referring the patient back to the GP or other suitable health professional if required).

Apply as early as possible as we may close to job advert early if we receive a sufficient number of applications.

Please note the job location may be subject to change due to the nature of PCN work.

Person Specification

Qualifications

Essential

• Good general standard of education (e.g. GCSEs or equivalent)

Desirable

• Administration-related qualification (e.g. NVQ in Business Admin or equivalent)
• Care Coordinator Formal Qualification
• Health and Social Care Qualification

Experience

Essential

• Significant experience in an administrative or coordination role, ideally with a proactive approach
• Experience working in health, social care, or a related front-facing environment
• Confidence in working with vulnerable individuals or those facing disadvantage
• Skilled at working empathetically and supportively with patients and carers
• Proficient in using databases and digital systems to manage and report information
• Experience of problem-solving and managing a varied, often reactive workload
• Working knowledge of confidentiality, safeguarding, and diversity principles
• Self-motivated, adaptable, and able to work both independently and within a team

Desirable

• Experience working in a multi-disciplinary team (e.g. alongside clinicians or care providers)
• Familiarity with care planning, personalised care, or case management
• Experience gathering information to determine patient needs and expectations
• Knowledge of social and health care systems and processes
• Understanding of relevant legislation, including Data Protection, safeguarding, and GDPR

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

SW Healthcare

Address

Henwick Halt Medical Centre

1 Ingles Drive

Worcester

WR2 5HL

Employer's website

http://www.swhealthcare.org.uk (Opens in a new tab)