PCN Frailty Team Care Coordinator

Posting date:	13 November 2025
Salary:	£13.00 to £13.50 per hour
Additional salary information:	£13.00 - £13.50 an hour
Hours:	Full time
Closing date:	30 November 2025
Location:	Gloucester, GL1 2TZ
Company:	NHS Jobs
Job type:	Permanent
Job reference:	A0782-25-0059

Summary

Case Identification Support the Frailty Practitioner as required to undertake digital risk stratification Transpose data onto the Personalised Proactive Whiteboard (PPW), ready to enable care coordination Holistic Assessment Support the Frailty Practitioner to triage potential patients to determine who receives a Comprehensive Geriatric Assessment (CGA) Support the Frailty Practitioner to determine what action to take with those patients who do not receive a CGA, including ensuring actions are undertaken Contribute to the completion of CGAs as determined by the Frailty Practitioner, inputting the information gleaned into a digital template Personalised Care and Support Planning As determined by the Frailty Practitioner Ensure each patient who has a CGA has a Personalised Care and Support Plan (PCSP) that has been discussed and finalised with the patient and any carer/family; this will help to manage their needs and achieve better health and wellbeing outcomes Ensure a ReSPECT plan is completed for each patient who has a CGA Coordinated and Multi-Professional Working Be responsible for coordinating the care of each patient, ensuring close multi-agency and multi-professional working, especially with the local Integrated Neighbourhood Team(s), to facilitate delivery of each patients PCSP Use and be fully responsible for the care coordination function of the PPW as the method of managing and coordinating the care for each patient Be responsible for ensuring relevant colleagues complete their agreed interventions listed in the PCSP, escalating issues if required to the Frailty Practitioner Continuity of Care including Review Be responsible for ensuring each patient who has a CGA has their CGA/PCSP regularly reviewed (e.g. every six months) according to need Be responsible for ensuring each patient who has a significant life event is offered a review of their CGA/PCSP, e.g. when they have been admitted to hospital on a planned or unplanned basis, or had a fall, or a close family bereavement General Alongside the Frailty Practitioner, provide support to the Frailty Team Administrator as required. Identify carers and help them access services to support them, ensuring they are coded as a carer on the GP clinical system if they are a patient at the Practice Provide a single point of contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care. Assist people to access self-management education courses, peer support, health coaching and other interventions to enable them to better manage their health and wellbeing. Provide co-ordination and navigation across services, helping to ensure people and their carers receive a joined-up service and the appropriate support from the right person at the right time. Work collaboratively with GPs and other General Practice team members within the PCN to proactively identify and manage a caseload, and where appropriate, refer back to other health practitioners within the PCN. Support the co-ordination and delivery of multidisciplinary teams with the PCN, if required. Identify people, using tools such as the PPW, who may benefit from shared decision making and support PCN staff and people to be more prepared to have shared decision-making conversations Explore and assist people to access a personal health budget where appropriate and available. Undertake clinical coding to create reliable patient records used for diagnosing accurately, planning treatment, and ensuring patient safety. Competently use clinical systems and templates to capture, and report patient records. Follow-up on communications from out of hospital and in-patient services. Through the PPW and other methods, maintain records of referrals and interventions to enable monitoring and evaluation of the service. Contribute to risk and impact assessments, monitoring and evaluation of the service Work with commissioners, Integrated Neighbourhood Team members and other agencies to support and further develop the Care Coordinator role and the work of the wider PCN Frailty Team Other responsibilities Applying PCN policies, standards and guidance Contributing to the teaching and training of trainees, new employees and employees who are undertaking training Awareness of and compliance with all relevant G DOC policies/guidelines for your role, e.g. prescribing, confidentiality, data protection, health and safety Contributing to evaluation/audit and clinical standard setting within the organisation as applicable to your role Attending training,meetings and other meetings and events organised by the Practices, PCN, or other agencies such as the ICB Contributing to audits and written returns to ensure that the PCN meets quality standards and receives the designated funding, as appropriate to your role Please see full job description attached