PCN Frailty Team Care Coordinator

G DOC Ltd; Lydney; On-site; GBP 25,000 - 35,000; Part time

Job summary

A healthcare organization in the Forest of Dean is seeking a Care Coordinator to work within a new Frailty team. This role involves coordinating care for individuals living with frailty and dementia, ensuring a personalized approach across health services. The successful candidate will have strong communication and organizational skills, and relevant experience in a healthcare environment. The position is part-time, offering up to 30 hours a week.

Benefits

Flexible hours

Support for professional development

Community-focused work environment

Qualifications

• Experience in an administrative role or within an NHS or healthcare setting.
• Ability to manage sensitive information with discretion.
• Understanding of personalized care and the holistic needs of people living with frailty.

Responsibilities

• Support the Frailty Practitioner with case identification and care planning.
• Coordinate care for patients, ensuring communication across services.
• Maintain personal patient records and support for ongoing evaluations.

Skills

Excellent communication skills

Organizational skills

Problem-solving skills

Compassionate care and empathy

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 playa vital role in a brand new Frailty team within our developing PCN. We are looking for an experienced and highly organised CareCoordinator to work with people living with moderate or severefrailty and/or dementia to provide co-ordination and navigation of care andsupport across health, care and support services. The role works closely with GPs, Practiceteams, Social Prescriber and wider PCN team to provide a personalised careapproach. The Care Coordinator will actas a central point of contact to ensure appropriate support is made availableto people and their carers; enabling them to understand and manage theircondition and ensuring their changing needs are addressed.

You will be based in theForest of Dean (location to be agreed) and you must be prepared to work acrossvarious locations in the Forest of Dean and occasionally may be required toattend GDOCs offices in Gloucester.

The post holder will work closelywith other members of the Frailty team including the Frailty Practitioner and FrailtyAdministrators.

Hours: Up to 30 hours per week

The closing date is 30thNovember 2025

Main duties of the job

Support the FrailtyPractitioner with case identification using digital risk stratification

Use and maintain thePersonalised Proactive Whiteboard to enable coordination of care

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

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

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

Ensure relevantcolleagues complete their agreed interventions listed in the PCSP, escalatingwhere necessary.

Regular review ofpatients to ensure continuity of care

Support other members of the Frailty Team includingPractitioners and Administrators.

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

Support coordination and delivery of MDTs.

Work collaboratively with GPs and other General PracticeTeam Members

Update patient records including clinical coding

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

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

Frequent prolonged VDU use

About us

The Care QualityCommission requires us to have a complete employment history from the age of16, including explanations for any gaps in employment.

You will be required to be immunised in compliance with Green Book (linkattached) and NHS recommendations for your role (unless medically exempt),including immunisations against Covid

West FOD PCN is hosted by G DOC LTD.

G DOC LTD is a unique, GP-owned organisation. All GPsurgeries in Gloucestershire are our shareholders. We operate with anot-for-profit ethos, ensuring every decision and service is focused onimproving patient outcomes and reinvesting in local Primary Care across thecounty.

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

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

Job responsibilities

Case Identification

Supportthe Frailty Practitioner as required to undertake digital risk stratification

Transpose dataonto the Personalised Proactive Whiteboard (PPW), ready to enable carecoordination

Support the FrailtyPractitioner to triage potential patients to determine who receives aComprehensive Geriatric Assessment (CGA)

Support the FrailtyPractitioner to determine what action to take with those patients who do notreceive a CGA, including ensuring actions are undertaken

Contribute to the completionof CGAs as determined by the Frailty Practitioner, inputting the informationgleaned into a digital template

PersonalisedCare and Support Planning

As determined by the FrailtyPractitioner

Ensureeach patient who has a CGA has a Personalised Care and Support Plan (PCSP) thathas been discussed and finalised with the patient and any carer/family; thiswill help to manage their needs and achieve better health and wellbeingoutcomes

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

Coordinatedand Multi-Professional Working

Be responsible forcoordinating the care of each patient, ensuring close multi-agency andmulti-professional working, especially with the local Integrated NeighbourhoodTeam(s), to facilitate delivery of each patients PCSP

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

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

Continuityof Care including Review

Be responsible for ensuringeach patient who has a CGA has their CGA/PCSP regularly reviewed (e.g. everysix months) according to need

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

General

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

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

Provide a single point ofcontact to answer queries, make and manage appointments, and ensure that peoplehave good quality written or verbal information to help them make choices abouttheir care.

Assist people to accessself-management education courses, peer support, health coaching and otherinterventions to enable them to better manage their health and wellbeing.

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

Work collaboratively withGPs and other General Practice team members within the PCN to proactivelyidentify and manage a caseload, and where appropriate, refer back to otherhealth practitioners within the PCN.

Support the co-ordinationand delivery of multidisciplinary teams with the PCN, if required.

Identify people, using toolssuch as the PPW, who may benefit from shared decision making and support PCNstaff and people to be more prepared to have shared decision-makingconversations

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

Undertake clinical coding tocreate reliablepatient records used for diagnosing accurately, planning treatment, andensuring patient safety.

Competently use clinicalsystems and templates to capture, and report patient records.

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

Through the PPW and othermethods, maintain records of referrals and interventions to enable monitoringand evaluation of the service.

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

Work withcommissioners, Integrated Neighbourhood Team members and other agencies tosupport and further develop the Care Coordinator role and the work of the widerPCN Frailty Team

Other responsibilities

Applying PCNpolicies, standards and guidance

Contributingto the teaching and training of trainees, new employees and employees who areundertaking training

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

Contributingto evaluation/audit and clinical standard setting within the organisation asapplicable to your role

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

Contributingto audits and written returns to ensure that the PCN meets quality standardsand 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.