PCN Frailty Team Care Coordinator

NHS; Forest of Dean; Hybrid; GBP 30,000 - 35,000; Full time

Job summary

A healthcare organization in the UK is seeking a Care Coordinator for its Frailty team. This role involves coordinating care for individuals living with frailty or dementia, providing support, and acting as a central point of contact. Working closely with GPs and a multi-disciplinary team, you will ensure comprehensive care plans for patients, highlighting the importance of collaboration and patient-centred approaches. The position requires strong communication skills, organizational abilities, and a commitment to high standards in healthcare delivery.

Qualifications

• Experience in an NHS or healthcare setting is preferred.
• Experience of working in an administrative role is beneficial.
• Ability to work under pressure and prioritize tasks.

Responsibilities

• Coordinate care for patients with frailty and dementia.
• Support the Frailty Practitioner with assessments and case identification.
• Ensure continuity of care through regular reviews.

Skills

Excellent communication

Organisational skills

Ability to manage sensitive information

Proactive problem-solving

Empathy and kindness

Education

GCSE grade 4/C or above in maths & English or equivalent

Tools

Microsoft Office

SystmOne

Job description

We are recruiting a Care Coordinator to play a vital role in a brand new Frailty team within our developing PCN. We are looking for an experienced and highly organised Care Coordinator to work with people living with moderate or severe frailty and/or dementia to provide coordination and navigation of care and support across health, care and support services. The role works closely with GPs, Practice teams, Social Prescriber and wider PCN team to provide a personalised care approach. The Care Coordinator will act as a central point of contact to ensure appropriate support is made available to people and their carers; enabling them to understand and manage their condition and ensuring their changing needs are addressed.

The job is primarily Forest of Dean based (location to be confirmed), but you will be required to travel independently between G DOCs services in Gloucestershire, including Gloucester and the Forest of Dean, and to attend meetings etc. hosted by other agencies throughout Gloucestershire and, occasionally, in other areas of the UK.

The post holder will work closely with other members of the Frailty team including the Frailty Practitioner and Frailty Administrators.

Hours: Up to 37.5 hours per week

The closing date is 31st January 2026

The job description for all G DOC workers also forms part of your job description.

Main duties of the job

Support the Frailty Practitioner with case identification using digital risk stratification

Use and maintain the Personalised Proactive Whiteboard to enable coordination of care

Support Frailty Practitioner to triage patients, complete comprehensive Geriatric Assessments (CGA) and determine and monitor actions.

Ensure relevant patients have a Personalised Care and support Plan (PCSP) and a ReSPECT form.

Coordinating the care of each patient, ensuring close multi-agency and multi-professional working.

Ensure relevant colleagues complete their agreed interventions listed in the PCSP, escalating where necessary.

Regular review of patients to ensure continuity of care

Support other members of the Frailty Team including Practitioners and Administrators.

Provide a single point of contact for patients and provide coordination and navigation across services.

Support coordination and delivery of MDTs.

Work collaboratively with GPs and other General Practice Team Members

Update patient records including clinical coding

Through the PPW and other methods, maintain records of referrals and interventions to enable monitoring and evaluation of the service

Please see job description and Frailty Team Functions Overview documents for further information.

Frequent prolonged VDU use

TheCare Quality Commission requires us to have a complete employment history from the age of 16, including explanations for any gaps in employment

About us

West FOD PCN is hosted by G DOC LTD.

G DOC LTD is a unique, GP-owned organisation all GP surgeries in Gloucestershire are our shareholders. We operate with a not-for-profit ethos, ensuring every decision and service is focused on improving patient outcomes and reinvesting in local Primary Care across the county.

We directly manage several GP surgeries in Gloucester and the Forest of Dean, providing patient-centred care to more than 45,000 patients. We value continuity of care and practice teams are at the heart of all we do. In addition to our surgeries, we deliver a range of countywide commissioned services designed to improve access, increase capacity, or provide specialist support. Our teams are committed to delivering sustainable, high-quality primary care while fostering innovation and collaboration across the local health system.

By joining us, you'll be part of an organisation that puts people first supporting staff wellbeing, professional development, and a collaborative culture. You'll benefit from the stability, support, and career opportunities of a larger organisation, while still working in close-knit, community-focused teams.

Job responsibilities

Case Identification

Support the Frailty Practitioner as required to undertake digital risk stratification

Transpose data onto the Personalised Proactive Whiteboard (PPW), ready to enable care coordination

Support the Frailty Practitioner to triage potential patients to determine who receives a Comprehensive Geriatric Assessment (CGA)

Support the Frailty Practitioner to determine what action to take with those patients who do not receive a CGA, including ensuring actions are undertaken

Contribute to the completion of CGAs as determined by the Frailty Practitioner, inputting the information gleaned into a digital template

Personalised Care and Support Planning

As determined by the Frailty Practitioner

Ensure each patient who has a CGA has a Personalised Care and Support Plan (PCSP) that has been discussed and finalised with the patient and any carer/family; this will help to manage their needs and achieve better health and wellbeing outcomes

Ensure a ReSPECT plan is completed for each patient who has a CGA

Coordinated and Multi-Professional Working

Be responsible for coordinating the care of each patient, ensuring close multi-agency and multi-professional working, especially with the local Integrated Neighbourhood Team(s), to facilitate delivery of each patient’s PCSP

Use and be fully responsible for the care coordination function of the PPW as the method of managing and coordinating the care for each patient

Be responsible for ensuring relevant colleagues complete their agreed interventions listed in the PCSP, escalating issues if required to the Frailty Practitioner

Continuity of Care including Review

Be responsible for ensuring each patient who has a CGA has their CGA/PCSP regularly reviewed (e.g. every six months) according to need

Be responsible for ensuring each patient who has a significant life event is offered a review of their CGA/PCSP, e.g. when they have been admitted to hospital on a planned or unplanned basis, or had a fall, or a close family bereavement

General

Alongside the Frailty Practitioner, provide support to the Frailty Team Administrator as required.

Identify carers and help them access services to support them, ensuring they are coded as a carer on the GP clinical system if they are a patient at the Practice

Provide a single point of contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care.

Assist people to access self-management education courses, peer support, health coaching and other interventions to enable them to better manage their health and wellbeing.

Provide co-ordination and navigation across services, helping to ensure people and their carers receive a joined-up service and the appropriate support from the right person at the right time.

Work collaboratively with GPs and other General Practice team members within the PCN to proactively identify and manage a caseload, and where appropriate, refer back to other health practitioners within the PCN.

Support the coordination and delivery of multidisciplinary teams with the PCN, if required.

Identify people, using tools such as the PPW, who may benefit from shared decision making and support PCN staff and people to be more prepared to have shared decision-making conversations

Explore and assist people to access a personal health budget where appropriate and available.

Undertake clinical coding to create reliable patient records used for diagnosing accurately, planning treatment, and ensuring patient safety.

Competently use clinical systems and templates to capture, and report patient records.

Follow-up on communications from out of hospital and in-patient services.

Through the PPW and other methods, maintain records of referrals and interventions to enable monitoring and evaluation of the service.

Contribute to risk and impact assessments, monitoring and evaluation of the service

Work with commissioners, Integrated Neighbourhood Team members and other agencies to support and further develop the Care Coordinator role and the work of the wider PCN Frailty Team

Other responsibilities

Applying PCN policies, standards and guidance

Contributing to the teaching and training of trainees, new employees and employees who are undertaking training

Awareness of and compliance with all relevant G DOC policies/guidelines for your role, e.g. prescribing, confidentiality, data protection, health and safety

Contributing to evaluation/audit and clinical standard setting within the organisation as applicable to your role

Attending training, meetings and other meetings and events organised by the Practices, PCN, or other agencies such as the ICB

Contributing to audits and written returns to ensure that the PCN meets quality standards and receives the designated funding, as appropriate to your role

Please see full job description attached

Person Specification

Qualifications

• GCSE grade 4/C or above in maths & English, or equivalent
• Clear, polite telephone manner
• Polite and confident
• Flexible and cooperative, motivated
• High levels of integrity and loyalty
• Demonstrates empathy, respect, and kindness in all interactions
• Collaborative and able to work effectively across disciplines and organisations to deliver joined-up care
• Person centred (Prioritises the individuals needs, preferences, and dignity)
• Innovative: Seeks out and applies evidence-based practices and new models of care
• Promotes equality, diversity, and cultural competence in care delivery
• Able to use own initiative but also know when to seek assistance
• Ability to work under pressure
• Willingness to embrace change and contribute to ongoing improvements within the service
• Takes responsibility for tasks and service outcomes, ensuring high standards in service delivery
• Engages in continuous professional development and reflective practice

Knowledge and Skills

• Excellent communication (written and oral) and interpersonal skills, comfortable and confident in communicating with a wide variety of people and organisations
• Competent in using Microsoft office software, including word processing and spreadsheets
• If not already competent in SystmOne, willing and able to undertake training and develop competency
• Ability to manage sensitive information with discretion and adhere to confidentiality requirements
• Proactive and problem-solving skills and the ability to work under pressure in a fast-paced environment
• Ability to follow policy and procedure
• Effective time management (organising and planning)
• Ability to work independently, as well as part of a team
• Strong organisational skills including planning, prioritising and record keeping
• Understanding of personalised care, wider determinants of health and equality, diversity and inclusion
• Ability to provide non-judgemental, culturally sensitive support using health coaching approaches
• Understanding of the holistic needs of people living with frailty and long-term conditions particularly in relation to promoting their independence
• Able to support data collection and use of tools to measure impact of services
• Knowledge of healthcare administration and familiarity with medical terminology
• Competent in use of SystmOne

Experience

• Experience of working in an administrative role
• Experience in an NHS or other healthcare setting
• Broad experience of General Practice

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.