Frailty Care Navigator Inner City PCN
| Posting date: | 21 January 2026 |
|---|---|
| Salary: | Not specified |
| Additional salary information: | Negotiable |
| Hours: | Full time |
| Closing date: | 08 February 2026 |
| Location: | Gloucester, GL1 2TZ |
| Company: | NHS Jobs |
| Job type: | Contract |
| Job reference: | A0782-26-0006 |
Summary
Duties Assist practices to identify and work with frail/elderly people and their carers, to provide coordination and navigation of care and support across health and care services. 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: o 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 o Ensure a ReSPECT plan is completed for each patient who has a CGA General 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. Work closely with GPs and practice teams to support them to manage patients to develop individual personalised care and support plans, ensuring appropriate support is made available to patients and carers, helping them to understand and manage their condition and ensure changing needs are addressed. Review patients needs and help them access the services and support they require to understand and manage their own health and wellbeing Liaise and work with the ICB, practices, voluntary and other organisations to implement patient services Assist the Business Manager in collating information for claims (e.g. ARRS, Care Homes, etc) and responding to queries Monitor the PCNs generic mailboxes and respond appropriately to emails Coordinate, organise and attend various MDT meetings (e.g. Care Homes, Dementia, Respiratory and Pain Management). Assist the Lead education GP to organise training including PLT sessions Support the Business Manager to deliver key projects, including quality improvement projects. This includes the provision of information and analysis using information, data, knowledge and technology systems to inform and support PCN agreed initiatives and meet the needs of the local population. Support the PCN Leadership team in the delivery of the DES specifications and support Quality and Outcome Frameworks. Assess data, monitor the PCN dashboard and liaise with the Digital and Transformation Leads, Practices, GPs and Nursing teams, with a view to achieving network targets and obtaining maximum investment and impact funding Attend meetings on behalf of the PCN Take minutes of meetings as required. Raise awareness of health promotion in practices, implementing, co-ordinating and supporting a variety of projects. Assist the Clinical Director and Business Manager to coordinate the Covid Vaccination programmes across practices Support the PCN practices, contributing to the delivery of QOF and enhanced services. Contributing to the management and development of the Primary Care Network, including the performance of work undertaken by the Practice as part of the PCN Helping to ensure that the PCN remains safe and effective, including by the use of clinical audit and learning from significant events and complaints. Working conditions Frequent, prolonged VDU use Time-pressured environment High levels of accuracy and attention to detail essential at all times Exposure to distressing situations and written material Job Description for all G DOC workers The job description for all G DOC workers also forms part of your job description.