Frailty Care Coordinator
Posted 3 hours 34 minutes ago by NHS
Carecoordination in General Practice is part of an exciting programme oftransformation to develop a new model of care which addresses our ambition todeliver a person-centered coordinatedcare.
CareCoordinators proactively identify and work with specified cohorts of people tosupport their personalised care requirements, using the available decisionsupport aids and MDTs. They act as the pivotal point of coordination forspecified groups of patients and bring together all of a persons identifiedcare and support needs, and explore their options to meet these into a singlepersonalised care and support plan, in line with PCSP best practice. This rolewill initially focus on established patient cohorts but will expand to developsupport for our population needing proactive care and integration with ourlocal ICT.
Main duties of the job- Coordinate and support the delivery of proactive, person-centred care for individuals living with frailty within the Primary Care Network (PCN).
- Organise and manage regular multidisciplinary team (MDT) hub meetings for the Whitewater Frailty Team and coordinate clinical team appointments, supporting the development of an integrated care hub and shared caseload across community and PCN nursing teams.
- Identify and work proactively with a cohort of patients requiring coordinated frailty care, supporting personalised care planning and ensuring their health and wellbeing needs are addressed through a single Personalised Care and Support Plan (PCSP).
- Act as a key point of contact for patients and carers, providing guidance, answering queries, and supporting access to appointments, services and appropriate benefits where eligible.
- Facilitate communication between clinicians, referrers and partner organisations, ensuring timely updates on patient progress and outcomes.
- Liaise with community services, social prescribers, health and wellbeing coaches, MIND wellbeing workers and other agencies to coordinate holistic care and ensure appropriate referrals and follow-up.
- Support health promotion initiatives including NHS Health Checks, national screening and immunisation programmes, including outreach activity such as care home visits.
- Assist clinicians with referrals, track progress of care plans and ensure tasks are completed.
Whitewater Health is a progressive and patient-focused GP practice located in Northeast Hampshire, operating across two sites in Hook and Hartley Wintney. We serve a diverse and growing population of approximately 18,000, providing high-quality, accessible healthcare with a strong emphasis on continuity of care, innovation, and collaborative working.
As a training and teaching practice, we are proud to support the development of clinicians at all stages of their careers, fostering a culture of learning, reflection, and clinical excellence. Our multidisciplinary team includes GPs, ACP's, Frailty team, practice nurses, HCAs, pharmacists, social prescribers, physiotherapists, and mental health practitioners, working together to deliver holistic care tailored to the needs of our patients.
We are rated Good by the Care Quality Commission and are actively engaged in quality improvement initiatives across the practice and wider Primary Care Network. Our commitment to staff wellbeing, professional development, and inclusive practice makes Whitewater Health a rewarding and supportive environment in which to thrive.
Job responsibilities- Coordinate and manage regular multidisciplinary hub meetings, for the Whitewater Frailty Team.
- Manage the appointments of the clinical team.
- Develop and coordinate the integrated care team hub and development of a shared caseload between community nursing and PCN link nursing.
- Proactively identify and work with a cohort of people identified as needing proactive care to support their personalised care requirements, using the available decision support aids.
- Ensure regular and consistent communication with the referrer regarding patient progress and any complications or guidance suggested by the MDT.
- Raise awareness of health promotion and NHS health checks in practices.
- Support national screening programmes and immunization programmes in support of the identified patient cohort. This may involve going off-site, i.e.; to visit Care Homes.
- Assist clinicians with the completion of referral forms and monitor referrals to ensure tasks are completed and care delivered by keeping in regular contact.
- Direct liaison with multi agencies to coordinate care for patients.
- Refer to PCN social prescribers, health and wellbeing coach and MIND wellbeing workers where a patient is identified as potentially benefitting from this service.
- To support patient/carer contact roles, and collate patient and carer feedback on their experiences.
- Support Quality and Outcome Frameworks and other DES/LES specifications with service reporting.
- Maintain and develop engagement with all practice staff and encourage best practice.
- Act as the first port of call for patients, in their caseload in relation to their care.
- Bring together all of a persons identified care and support needs, and explore their options to meet these into a single personalised care and support plan (PCSP), in line with PCSP best practice.
- Help people to manage their needs, answering their queries and supporting them to make appointments.
- Support people to take up training, employment and access appropriate benefits where eligible.
- Raise awareness of shared decision-making and decision support tools, and assist people to be more prepared to have a shared decision-making conversation.
- Ensure that people have good quality information to help them make choices about their care.
- Support people to understand their level of knowledge, skills and confidence their Activation level when engaging with their health and wellbeing, including using the Patient Activation Measure.
- Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing.
- Explore and assist people to access personal health budgets where appropriate.
- Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers and other primary care roles.
- Support the coordination and delivery of MDTs within PCNs.
- Awareness of Safeguarding protocols.
- GCSE grade A to C in English and Maths
- Experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field (including unpaid work)
- Advanced experience of using word, excel and PowerPoint including ability to use word processing skills, emails and the internet to create simple plans and reports
- Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
- Able to work as part of a team
- Able to support people in a way that inspires trust and confidence, motivating others to reach their potential
- Ability to communicate effectively, both verbally and in writing, with people, their families, carers, partner agencies and stakeholders.
- Meets DBS reference standards and has a clear criminal record, in line with the law on spent convictions
- ECDL or equivalent
- Experience of dealing with vulnerable patients
- Experience of working with healthcare professionals and or previous experience in the NHS, social care or relevant field
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.