Frailty Care Navigator | Proactive Senior Care

Essex Partnership NHS Foundation Trust; Rochford; On-site; GBP 40,000 - 48,000; Full time

Benefits offered by this job

Season Ticket Loans

Excellent Training facilities and opps

Buying and Selling annual leave

Job summary

Essex Partnership University NHS Foundation Trust is seeking a Care Coordinator (Frailty) to assess and coordinate care for vulnerable older people. You will work with GPs, PCNs, hospital teams, and social care to develop proactive plans, manage risk, and ensure timely home visits after discharge.

You will contribute to the development of the care coordination model and support staff with data input, audits, and service improvement initiatives.

Qualifications

• Experience coordinating care for older people across services.
• Ability to engage with GP surgeries and PCNs for proactive patient identification.
• Strong communication with patients, carers, families and colleagues.

Responsibilities

• Coordinate care pathways for vulnerable older people across service interfaces.
• Engage with GP surgeries/PCNs to identify frail patients at risk of admission or loss of independence.
• Attend MDT meetings and develop proactive care plans before crises.
• Track patients admitted to hospital and manage discharge planning.
• Visit patients at home within 2 days of hospital discharge to review holistic needs.
• Ensure individualised care plans with focused goals.

Skills

Care coordination

Frailty assessment

MDT collaboration

Verbal & non‑verbal communication

Tools

Frailty tools

Risk assessment tools

Job description

Essex Partnership University NHS Foundation Trust is seeking a Care Coordinator (Frailty) to assess and coordinate care for vulnerable older people. You will work with GPs, PCNs, hospital teams, and social care to develop proactive plans, manage risk, and ensure timely home visits after discharge.

You will contribute to the development of the care coordination model and support staff with data input, audits, and service improvement initiatives.