Frailty Care Co-ordinator

The Methodist Church in Britain; Mount Hawke; Hybrid; GBP 26,000 - 32,000; Full time

Benefits offered by this job

Training provided for health checks

Job summary

The Methodist Church in Britain is recruiting for a Frailty Team post within Coastal Primary Care Network, based at St Agnes and Perranporth surgeries. The role is 18-month fixed term, with hours across part-time or full-time and travel between PCN sites including home visits.

Coordinate personalised care for frailty and complex needs, linking GP practices with community and voluntary services. Driving licence and vehicle access required for travel between sites and home visits.

Qualifications

• Educated to GCSE level or equivalent, including English and Mathematics.
• Evidence of continuing professional development.

Responsibilities

• Coordinate personalised care plans and act as a central contact for patients and families.
• Identify and manage caseloads of patients with frailty, long-term conditions, or complex social needs.
• Coordinate care across primary, secondary, community, social care and voluntary services; support transitions between them.
• Support patients after hospital discharge and identify those at risk of avoidable admission.
• Take part in multidisciplinary team meetings and coordinate actions arising from them.
• Assist patients in accessing community services and social prescribing; work with Social Prescribing Link Workers.
• Support long-term condition reviews, follow-up and annual reviews.
• Provide home assessments.
• Carry out basic physical health checks after training.
• Maintain accurate clinical records and produce reports.

Skills

Person-centred care

Multidisciplinary working

Communication

Time management

IT skills

Education

GCSE English & Maths

Tools

Microsoft Office

Job description

A new Frailty Team post with Coastal Primary Care Network, based at St Agnes and Perranporth surgeries, on an 18-month fixed term. The role coordinates personalised care for patients with frailty, long-term conditions or complex needs, linking GP practices with community, social care and voluntary services. Hours are part-time or full-time, with work across several sites and home visits. A driving licence and access to a vehicle are required for the travel involved.

What the job involves

• Coordinate personalised care plans and act as a central contact for patients and their families where appropriate
• Identify and manage caseloads of patients with frailty, multiple long-term conditions, complex social needs or involvement from several agencies
• Coordinate care across primary, secondary, community, social care and voluntary services, and support smooth transitions between them
• Support patients after hospital discharge, act on discharge summaries and identify those at risk of avoidable admission
• Take part in multidisciplinary team meetings and coordinate the actions arising from them
• Help patients access community, social prescribing and voluntary sector services, working alongside Social Prescribing Link Workers
• Support long-term condition reviews, follow-up and annual reviews
• Provide assessments in patients' homes
• Carry out basic physical health checks such as weight, blood pressure and blood tests, after training
• Maintain accurate clinical records and produce reports on activity and performance
• Recognise and respond to safeguarding concerns and escalated clinical and non-clinical risks promptly
• Contribute to service development, audit and evaluation, and support new pathways

Qualifications

• Educated to GCSE level or equivalent, including English and Mathematics
• Evidence of continuing professional development

Experience

• Working in health, social care, community or voluntary sector services
• Supporting vulnerable individuals
• Managing competing priorities and workloads
• Communicating with a range of stakeholders and professionals, and maintaining accurate records

Skills & knowledge

• Understanding of person-centred care and multidisciplinary working
• Knowledge of confidentiality, data protection and safeguarding responsibilities
• Awareness of health inequalities and the wider determinants of health
• Excellent communication skills and the ability to build relationships with patients and professionals
• Strong organisation, time management, and the ability to work independently and in a team
• Good problem-solving, strong IT skills including Microsoft Office, and handling sensitive or distressing situations

Checks & eligibility

• Full UK driving licence and access to a vehicle

Other

• Commitment to high-quality, patient-centred care
• Flexible approach to working across multiple sites
• Ability to travel between PCN locations and carry out home visits

Nice to have

• Experience in general practice or primary care
• Care coordination or case management experience
• Experience in multidisciplinary teams, with facilitation and meeting coordination skills
• Experience supporting frail patients or those with long-term conditions
• Care Coordinator qualification or Personalised Care Institute training
• Level 3 or above in health, social care or business administration, or equivalent experience
• Mental Health First Aid training or a health coaching qualification
• Knowledge of NHS systems and SystmOne, and experience with population health and reporting systems

What’s offered

• Training provided for basic physical health checks