PCN Frailty Team Care Coordinator
| Posting date: | 23 January 2026 |
|---|---|
| Salary: | Not specified |
| Additional salary information: | Negotiable |
| Hours: | Full time |
| Closing date: | 20 February 2026 |
| Location: | Cheltenham, GL53 0LA |
| Company: | NHS Jobs |
| Job type: | Permanent |
| Job reference: | A1910-25-0016 |
Summary
Key Responsibilities Case Identification: - Support the Frailty Nurse as required to undertake digital risk stratification - Transpose data onto our clinical systems, ready to enable care coordination Holistic Assessment: - Support the Frailty Nurse to triage potential patients to determine who receives an assessment - Support the Frailty Nurse to determine what action to take with those patients who do not receive an assessment, including ensuring actions are undertaken - Contribute to the completion of the assessments as determined by the Frailty Nurse, inputting the information gained into a digital template Personalised Care and Support Planning: As determined by the Frailty Nurse: - Ensure each patient who has an assessment has a Personalised Care and Support Plan 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 an assessment 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 personalised care and support plan - Use and be fully responsible for the care coordination function of our clinical systems 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 personalised care and support plan, escalating issues if required to the Frailty Nurse Continuity of Care including Review: - Be responsible for ensuring each patient who has an assessment has their plans 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 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 Nurse, provide leadership and 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, when required. - Identify people, using clinical tools, 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 our clinical systems and tools, 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 Team Care Coordinator role and the work of the wider PCN Frailty Team.