PCN Frailty Care Coordinator
| Posting date: | 16 December 2025 |
|---|---|
| Salary: | £25,361.00 per year |
| Additional salary information: | £25361.00 a year |
| Hours: | Full time |
| Closing date: | 29 January 2026 |
| Location: | Gloucester, GL3 2JH |
| Company: | NHS Jobs |
| Job type: | Permanent |
| Job reference: | A3666-25-0003 |
Summary
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.