PCN Frailty Care Coordinator

Job summary

North and South Gloucester Primary Care Network seek a dedicated Frailty Care Coordinator to join their 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.

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 setting, is essential.

A full UK driving licence and access to a vehicle are essential for this role due to travel to patients' homes and between sites.

The role will work closely with our Living Well Team's Frailty Administrator and some of the key responsibilities may be shared between the two post-holders.

The role is offered for between 30 to 37.5 hours per week, to be agreed with the successful applicant.

Main duties of the job

Care Coordinators play an important role within a PCN to proactively identify and work closely with people, including the frail/elderly and those with long term health conditions, to provide coordination and navigation for people and their carers across health and care services, helping to ensure patients receive a joined-up service and the most appropriate support.

As a key member of our Living Well Team, you will work closely with our GP practices and a wide range of health, social care and community partners to support our patient population. You will act as a first point of contact for patients, carers and professionals, handling queries by telephone, e-mail or in person in a calm and sensitive way, providing advice where possible and ensuring issues are followed up promptly.

You will identify and manage your own caseload of patients, carrying out home visits to complete/review Personalised Care Plans (e.g., Me @ my best, What Matters to Me) and undertake Dementia reviews. Training will be provided.

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 work within our 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 Living Well Team to address the needs of our population.

Key Responsibilities

• Provide coordination and navigation for people and their carers across health and care services, working closely with our Living Well Team (Social Prescribing Link Workers, Frailty Nurses and Care Coordinators) and all members of our primary care teams.
• Act as a first point of contact for patients, carers and professionals, handling queries by telephone, e-mail or in person in a calm and sensitive way, providing advice where possible and ensuring issues are followed up promptly with the right team member.
• Identify and manage own caseload of patients, carrying out home visits to complete/review Personalised Care Plans (e.g., Me @ My Best, What Matters to Me), and undertake dementia reviews. Training will be provided.
• Help people to manage their needs through answering queries, making and managing appointments, ensuring people have good quality written or verbal information to help them make choices about their care.
• Work sensitively with people, their families and carers to improve their understanding of the patient's condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
• 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 data.
• Contribute to local Multi-Disciplinary Team meetings within the Network, following up actions within defined timescales as agreed during the meeting.
• Collate relevant information and ensure accurate documentation and signposting in line with NHS policies and confidentiality standards.
• Maintain accurate and up-to-date patient and service records, including inputting data into electronic systems (e.g., EMIS, SystmOne or local databases).
• Assist with the management of the Living Well Team's recall system, ensuring patients are coded appropriately and followed up in a timely manner in line with agreed protocols.
• Assist with the distribution of Health and Wellbeing Self-Assessment questionnaires, ensuring responses are recorded accurately and any necessary follow-up actions are completed.
• Assist in the preparation of patient information, resources and communication materials.
• Liaise with internal and external stakeholders, including healthcare professionals, local authorities and voluntary sector organisations.
• Contribute to the continuous improvement of administrative and care coordination processes to enhance efficiency and patient experience.

Person Specification

Qualifications

Essential

• Good standard of education with 5 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

• Proven experience in a similar role, ideally within healthcare or social care settings.
• Excellent communication skills, both verbal and written, with a professional, empathetic and approachable manner.
• Ability to explain complex information clearly to patients, carers and professionals.
• Ability to use coaching techniques to empower patients and carers.
• Ability to manage own caseload of patients.
• Commitment to improving the quality of life for older people.
• Ability to build positive relationships across health and social care partners.
• Excellent organisational and time-management skills, with the ability to manage multiple tasks and changing priorities.
• Strong IT skills, including Microsoft Office (Word, Excel, Outlook) and familiarity with NHS patient record systems.
• High attention to detail and accuracy in record keeping and correspondence.
• Ability to work effectively both as part of a multi-disciplinary Team and independently when required.
• Understanding of data protection, confidentiality and GDPR requirements.

Desirable

• Previous experience in a primary care, community care or integrated care setting.
• Knowledge of health and social care pathways relevant to wellbeing, independence and long-term conditions.
• Awareness of NHS safeguarding principles.
• Awareness of Comprehensive Geriatric Assessment (CGA) principles.
• Knowledge of SystmOne/EMIS Patient Clinical Systems.

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.

For more details regarding the person specification or to apply online, please click on Apply Now.

Further details to the right of this advert.