PCN Frailty and Data Analyst / Care Home Care Coordinator

Vertis Health; Droitwich Spa; On-site; GBP 32,000 - 45,000; Full time

Job summary

The PCN Frailty and Data Analyst / Care Home Care Coordinator will play a key role in supporting the PCN's proactive approach to frailty, population health management and the delivery of integrated, person-centred care.

The postholder will identify and analyse patient populations, support risk stratification and monitor service performance to inform clinical decision-making and service improvement.

Responsibilities

• Frailty identification and population health management.
• Data analysis, reporting and performance monitoring.
• Develop, run and maintain clinical searches using EMIS Web and other approved systems.
• Support the identification of priority frailty cohorts (65+, Rockwood scores).
• Coordinate care for residents as part of PCN Care Home Team.
• Improve communication between services and ensure timely, joined-up support.

Tools

EMIS Web

Job description

PCN Frailty and Data Analyst / Care Home Care Coordinator

The PCN Frailty and Data Analyst / Care Home Care Coordinator willplay a key role in supporting the PCN's proactive approach to frailty,population health management and the delivery of integrated, person-centredcare.

The postholder will be responsible for identifying and analysingpatient populations, supporting risk stratification, monitoring serviceperformance and providing accurate, meaningful data to inform clinicaldecision-making, service improvement and strategic planning.

Working closely with the PCN Frailty ACP, GP practices andmultidisciplinary teams, the postholder will support the identification ofpatients living with moderate to severe frailty, helping to ensure thatappropriate interventions, assessments and care planning are prioritised.

The role will also include one dedicated day per week working as aCare Coordinator within the PCN Care Home Team, supporting the coordination ofcare for residents, improving communication between services and ensuringpatients receive timely, joined-up support.

The postholder will contribute to the PCN's wider neighbourhoodhealth and population health management objectives, including reducingavoidable hospital admissions, improving proactive care and supporting patientsto remain well and independent for as long as possible.

Main duties of the job

Key responsibilities:

• Frailty identification and population health management
• Data Analysis, reporting and performance monitoring
• Frailty service development and quality improvement
• Communication and collaborative working
• Information governance and confidentiality
• General responsibilities

About us

AboutDroitwich Ombersley & the Rurals Primary Care Network

Droitwich,Ombersley & The Rurals PCN consists of 7 practices, based across SouthWorcestershire, serving 57,000 patients. We aim to offer and deliver excellent,safe, co-ordinated, high-quality patient care. Continuously learning, evolving,and implementing new models of care, to create inclusion, reduce healthinequalities and health improve outcomes.

Wework hard to promote a culture where staff feel engaged, valued, and recognisedby the organisation and the others they work with.

Wehave an Additional Roles team of 35 healthcare professionals and are lookingfor an individual with a passion to deliver excellent service in GeneralPractice and in the local communities.

Job responsibilities

2. Key Responsibilities

Frailty Identification and Population Health Management

• Support the identification and monitoring of patients living with moderate to severe frailty across the PCN.
• Develop, run and maintain clinical searches using EMIS Web and other approved clinical and population health management systems.
• Support the identification of priority frailty cohorts, including patients aged 65 and over, those with Rockwood Clinical Frailty Scores of 69 and housebound patients.
• Work alongside the Frailty ACP, GP practices, and other stakeholders to identify patients who may benefit from proactive assessment, intervention or multidisciplinary review.
• Support the development and maintenance of frailty registers, ensuring data is accurate, current and appropriately coded.
• Identify patients requiring Comprehensive Geriatric Assessments (CGA), reviews or proactive interventions, referring these to the appropriate clinician or team for consideration.
• Undertake regular reviews of frailty population data to identify changes in risk, emerging needs and opportunities for earlier intervention.
• Support the identification of patients at increased risk of hospital admission, deterioration or poor health outcomes.
• Assist with identifying gaps in care and inequalities in access to frailty services.
• Work with clinical teams to support targeted interventions and proactive care planning.

Data Analysis, Reporting and Performance Monitoring

• Collect, analyse and interpret clinical and operational data to support the delivery of PCN priorities.
• Develop and maintain spreadsheets, dashboards and reports to monitor frailty activity, outcomes and service performance.
• Produce regular reports for the PCN Operations Manager, Clinical Director, Frailty ACP and PCN Board.
• Monitor key performance indicators, including:
• Identification and prevalence of moderate to severe frailty.
• Completion of Comprehensive Geriatric Assessments.
• Proactive care reviews and personalised care plans.
• Emergency department attendances and non-elective hospital admissions.
• Hospital bed days and readmissions, where data is available.
• Care home activity and multidisciplinary reviews.
• Identification of patients approaching end of life and appropriate care planning.
• Health inequalities and variation between practices.
• Support the collection and analysis of data required for PCN contractual requirements, locally commissioned services and neighbourhood health programmes.