Urgent Care, Dementia and Frailty Care Co-ordinator
| Posting date: | 07 July 2025 |
|---|---|
| Salary: | £27,485.00 to £30,162.00 per year |
| Additional salary information: | £27485.00 - £30162.00 a year |
| Hours: | Full time |
| Closing date: | 20 July 2025 |
| Location: | Stockport, SK1 1PN |
| Company: | NHS Jobs |
| Job type: | Permanent |
| Job reference: | B0463-25-0003 |
Summary
Main Roles & Responsibilities: To work as a team of Urgent Care, Frailty and Dementia Care Coordinators, with the GPs and other primary care professionals within the PCN to proactively identify and support some of our most vulnerable patients who require additional input due to their presentation. The focus being those patients with moderate to severe frailty, those with a diagnosis of dementia or cognitive impairment, and those returning home after a recent admission to hospital, with the aim of delivering proactive and reactive care to this group of patients. Be flexible to work collaboratively and support the other care coordinator teams across the PCN with work that is required as directed by the PCN management team. Be responsible for running weekly EMIS searches to identify those moderately and severely frail patients, those with recent admissions to hospital or ED attendances, particularly those attending with falls and those with known dementia, contacting patients to arrange appointments, whether in their own homes or bringing them into clinic. To visit these patients in their own homes or see them within the practice where appropriate to complete a holistic review of the patients health and social needs following an agreed assessment pathway. Data collection and submission, filing, general admin etc. Bring together all a persons identified care and support needs and what matters to them; explore the options to address these in a single personalised care and support plan created in collaboration with the patient and their family as appropriate. To support with venepuncture and NHS Health Checks (pulse measurement, blood pressure monitoring, height and weight measurement and waist measurement) where required. Communicating at least monthly with the PCN management team about ongoing workstreams and work completed. Raise awareness of shared decision-making and decision support tools and assist people to be more prepared to have a shared decision-making conversation. 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. Support the coordination and delivery of multidisciplinary teams within PCN, in particular working with the PCN Pharmacy team. Provide coordination and navigation for individuals and their carers across health and care services, working closely with social prescribing link workers and other primary care roles such as the Advanced Community Practitioners/District nurses To help patients to manage their needs through answering queries, making, and managing appointments Assist and coordinate practices in meeting PCN DES, Locally Commissioned Service Targets and Impact and Investment Fund (IIF) targets, and practice Quality Outcomes Framework (QoF) targets. Responsible for coordinating any joint projects, e.g. vaccination and any associated administration It should be noted that whilst this job description lists the main areas of responsibility, there may be additional tasks appropriately assigned by either the Clinical Director or PCN Lead Manager to this role.