Urgent Care, Dementia and Frailty Care Co-ordinator

Integrated Care System; Stockport; On-site; GBP 27,000 - 31,000; Full time

Job summary

Join a leading care organization as an Urgent Care, Dementia, and Frailty Care Co-ordinator, contributing to a primary care network in Stockport. This role involves coordinating care for vulnerable patients and fostering interdisciplinary collaboration to improve patient outcomes. You will play a vital role in supporting older adults and their families while ensuring effective management of their health needs.

Benefits

Employee assistance programme

Extensive training opportunities

Up to five paid study days annually

Qualifications

• Experience working with older adults, dementia, frailty, or falls risk.
• Ability to conduct comprehensive assessments.
• Experience working autonomously and in teams.

Responsibilities

• Coordinate interdisciplinary care for patients with complex needs.
• Support vulnerable patients and develop personalized care plans.
• Run EMIS searches and manage patient appointments.

Skills

Communication

Interpersonal Skills

Independent Work

Person-Centered Support

Education

Grade C or above in English and Maths GCSE or equivalent

NVQ Level III (Health and Social Care) or equivalent experience

Venepuncture training or willingness to undertake training

PCI Accredited Care Coordinator training or willingness to undertake

Tools

Microsoft Office

Job description

Urgent Care, Dementia and Frailty Care Co-ordinator

We have a fantastic opportunity to join our innovative team of Care Co-ordinators working in the Stockport East and South (SES) Primary Care Network (PCN) in Stockport, specialising in Dementia and Frailty.

Two positions are available, and this role will involve working with patients with a range of presentations and their families and carers. The Care Co-ordinator will be integral in overseeing the interdisciplinary care and will be responsible for co-ordinating a package of care and support from a variety of specialists who may be working with the patient.

You will support all key activity across the PCN; supporting the PCN Manager and associated practices by co-ordinating activity and providing an efficient, well organised administrative and operational support to the clinicians and managers in the network to ensure effective timely delivery of the PCN objectives.

Main duties of the job

Care Co-ordinator roles are new to Primary Care, and we are looking to recruit an Urgent Care, Frailty and Dementia Care Co-ordinator within the SES Primary Care Network (PCN) across the borough. This role involves working with patients with a range of presentations and their families and carers. The care co-ordinator will oversee interdisciplinary care and be responsible for co-ordinating a package of care and support from various specialists involved with the patient.

About us

Viaduct Care CIC is the company structure for Stockport's GP Federation, representing all its local GP Practices. Covering a patient population of circa 300,000, practices are split into 6 PCNs, each serving around 30,000-50,000 patients.

Viaduct Care represents the collective voice and interests of its member practices and, as a key stakeholder in Stockport Together, aims to influence and support service and system changes by partnering effectively with other providers.

Our priorities include team wellbeing and development. We offer an employee assistance programme, extensive training opportunities, and up to five paid study days annually.

Click on the Why Join Viaduct Care link to learn more about our staff support and benefits.

Job responsibilities

Main Roles & Responsibilities:

• Work collaboratively with GPs and primary care professionals within the PCN to proactively support vulnerable patients, particularly those with moderate to severe frailty, dementia, recent hospital admissions, or falls, delivering proactive and reactive care.
• Support other care coordinator teams across the PCN as directed by management.
• Run weekly EMIS searches to identify patients needing support, contact them to arrange appointments, and see them in their homes or clinics as appropriate.
• Complete holistic reviews of patients' health and social needs following assessment pathways.
• Collect and submit data, manage filing and general admin tasks.
• Develop personalized care and support plans in collaboration with patients and families.
• Support venepuncture and NHS Health Checks where required.
• Maintain regular communication with the PCN management team about ongoing workstreams.
• Promote shared decision-making and assist patients in accessing self-management education, peer support, and personal health budgets.
• Coordinate multidisciplinary teams within the PCN, especially working with the pharmacy team.
• Provide navigation and coordination for patients and carers across services, working closely with social prescribers and community practitioners.
• Support patients in managing their needs through queries, appointments, and information provision.
• Assist practices in meeting PCN DES, LCS, IIF, and QoF targets.
• Coordinate joint projects like vaccination programs and related admin.

Additional tasks may be assigned by the Clinical Director or PCN Lead Manager as needed.

Person Specification

Qualifications

• Grade C or above in English and Maths GCSE or equivalent.
• Venepuncture training or willingness to undertake training.
• PCI Accredited Care Coordinator training or willingness to undertake.
• NVQ Level III (Health and Social Care) or equivalent experience.
• Training in working with long-term conditions.

Experience

• Commitment to improving outcomes for older adults.
• Experience working autonomously and in teams.
• Experience with older adults, dementia, frailty, or falls risk.
• Ability to recognize and respond to risk and safeguarding concerns.
• Knowledge of confidentiality and data protection.
• Understanding of dementia, frailty, and falls risk.
• Knowledge of Adult Social Care frameworks and local services.
• Ability to undertake clinical observations and tests or willingness to learn.
• Experience with care planning tools and digital systems.
• Understanding polypharmacy and medication reviews.
• Experience working within multidisciplinary teams.

Skills and Other Attributes

• Excellent communication and interpersonal skills, including sensitive discussions about DNAR and future planning.
• Ability to conduct comprehensive assessments.
• Person-centered, non-judgmental support approach.
• Independent workload planning and prioritization.
• Accurate record-keeping and effective communication.
• Proficient in Microsoft Office and IT skills.
• Willingness to travel across Stockport and work from home if needed.
• Full, clean driving license and access to a car.
• Alignment with Viaduct Care CIC values and ethos.
• Flexibility to adapt to an evolving role.
• Experience working independently.

Additional Attributes

• Willing to travel and work across Stockport, including from home.
• Supportive of Viaduct Care CIC's values.
• Full, clean driving license and access to a car.
• Flexible working approach.

Disclosure and Barring Service Check

This role requires a Disclosure and Barring Service check due to the nature of the work with vulnerable populations.

Salary: £27,485 to £30,162 per year, pro-rata based on 37.5 hours/week.