Enhanced Frailty Health and Social Care Coordinator

NHS Jobs; Greater London; On-site; GBP 60,000 - 80,000; Full time

Job summary

A leading healthcare organization is seeking an Enhanced Frailty Health and Social Care Coordinator. In this role, you will work with GP surgeries to identify at-risk patients, coordinate care delivery among service providers, and maintain effective communication with patients and their families. The ideal candidate will possess basic computing skills and a strong commitment to patient welfare and service improvement. This position is based in Greater London.

Qualifications

• Basic computing skills required.
• Familiarity with relevant clinical systems and software needed.
• Participation in training is mandatory.

Responsibilities

• Identify potential referrals to the Tier 2 Frailty Service.
• Coordinate care delivery between service providers.
• Maintain relationships with long-term condition service providers.

Skills

Effective communication

Risk stratification

Case coordination

Job description

Enhanced Frailty Health and Social Care Coordinator

Main Responsibilities

1. Work with GP Surgeries to identify potential referrals to the Tier 2 Frailty Service.
2. Collaborate with Frailty Team colleagues, using risk stratification tools to identify at-risk patients and ensure timely assessment and care.
3. Support the delivery of Complex Care, coordinating between service providers as needed.
4. Make Social Prescribing referrals when appropriate.
5. Participate in team huddles and multidisciplinary meetings.
6. Hold regular welfare calls with patients and carers.
7. Maintain excellent relationships with all involved in long-term condition services, sharing updates on care plans and changes.
8. Work closely with the Frailty Team to ensure patients have relevant referrals and access; attend case conferences and provide updates.

Communication Skills

• Communicate effectively and welcomingly with patients, respecting their feelings and rights.
• Use sensitive communication styles, especially during welfare calls.
• Share sensitive patient information appropriately with team members and other providers.
• Ensure all notes are documented contemporaneously.

Supporting Responsibilities

• Reflect on team activities and suggest improvements.
• Participate in managing patient complaints and significant events.
• Deliver care based on NICE and CQC guidelines.

Information Technology

• Have basic computing skills.
• Be familiar with relevant clinical systems and software.
• Understand policies on information and clinical governance.

Research and Audit

• Contribute to data collection for research and audit.
• Identify relevant audit topics for the Frailty Team.

Professional and Educational Responsibilities

• Complete all statutory and mandatory training.
• Seek opportunities to develop clinical knowledge and practical skills.