Frailty Care Navigator for Integrated Community Health

Carnon Downs Surgery; Hugh Town; On-site; GBP 17,000 - 25,000; Full time

Job summary

Carnon Downs Surgery is recruiting Frailty Care Co-ordinators to join the Coastal PCN, probably based at St Agnes Surgery and Perranporth Surgery. Roles are part time or full time, focusing on coordinating care, navigating health and care services, and delivering timely, person-centred support.

The post involves working with GP practices, community services and social care to improve outcomes, with home visits and MDT involvement as core elements.

Qualifications

• Experience working in health, social care, community or voluntary sector services.
• Experience supporting vulnerable individuals.
• Experience managing competing priorities and workloads.
• Experience communicating with a range of stakeholders and professionals.
• Experience maintaining accurate records and documentation.

Responsibilities

• Coordinate and support the delivery of personalised care plans.
• Act as a central point of contact for patients and their families where appropriate.
• Support patients to access the right services at the right time.
• Coordinate care across primary care, secondary care, community services, social care and voluntary sector organisations.
• Facilitate smooth transitions between services.
• Ensure patients receive timely follow-up and ongoing support.
• Provide assessment within patient home settings.
• Identify patients who may benefit from care coordination including frail and elderly patients, patients with multiple long-term conditions, patients experiencing frequent hospital admissions, patients with complex social needs and patients requiring support from multiple agencies.
• Maintain patient caseloads and prioritise support according to need.
• Monitor progress against agreed care plans.
• Escalate concerns and risks appropriately.
• Work alongside patients to identify their needs, goals and preferences.
• Support shared decision-making.
• Promote self-management and patient activation.
• Support patients in understanding available healthcare and community resources.
• Assist in developing personalised care and support plans.
• Participate in MDT meetings.
• Coordinate actions arising from MDT discussions.
• Support communication between clinicians, practices, community teams and partner organisations.
• Facilitate information sharing in accordance with information governance requirements.
• Support proactive management of patients identified through frailty, population health and risk stratification programmes.
• Assist with long-term condition reviews and follow-up.
• Coordinate annual reviews where appropriate.
• Support implementation of PCN and Integrated Care System initiatives.
• Work closely with Social Prescribing Link Workers.
• Assist patients to access community-based services and support networks.
• Signpost patients to appropriate statutory and voluntary sector services.
• Support reduction of social isolation and health inequalities.
• Support patients following discharge from hospital.
• Assist with post-discharge follow-up activity.
• Coordinate actions arising from discharge summaries.
• Identify patients at risk of avoidable admission and work with the wider MDT to provide support.
• Maintain accurate patient records using clinical systems.
• Record activity in accordance with PCN, INT and contractual requirements.
• Produce reports and performance information as required.
• Ensure documentation is accurate, contemporaneous and compliant with information governance standards.
• Recognise and respond appropriately to safeguarding concerns.
• Follow local safeguarding procedures for children and adults.
• Escalate clinical and non-clinical risks promptly.
• Maintain patient confidentiality at all times.
• Contribute to continuous quality improvement initiatives.
• Participate in service evaluation and audit activities.
• Support implementation of new pathways and services.
• Share best practice and contribute to innovation across the PCN.

Skills

Communication

Interpersonal skills

Organisation

Problem solving

Team collaboration

Patient advocacy

Education

GCSE English and Maths

Evidence of continuing professional development

Tools

SystmOne

Population health systems

Microsoft Office

Job description

Carnon Downs Surgery is recruiting Frailty Care Co-ordinators to join the Coastal PCN, probably based at St Agnes Surgery and Perranporth Surgery. Roles are part time or full time, focusing on coordinating care, navigating health and care services, and delivering timely, person-centred support.

The post involves working with GP practices, community services and social care to improve outcomes, with home visits and MDT involvement as core elements.