PCN Frailty Team Care Coordinator

Cheltenham Peripheral Primary Care Network is looking to expand our PCN Frailty Team with the addition of a new Frailty Team Care Coordinator. This exciting new role offers a unique opportunity to make a real difference in the lives of the ageing population within our community.

We are seeking an innovative, accountable and compassionate individual who has exceptional interpersonal skills and a person-centred approach. You will be collaborative, self-motivated and well organised. Previous experience of working in a patient-facing health, social care or related support role, either in a clinical or non-clinical setting, is essential. You will also have good written, verbal communication and time management skills.

A full UK driving licence and access to a vehicle are essential for this role due to travel to patients' homes and between sites.

The role will work closely with our Teams Project Lead, Frailty Nurse and Team Administrator and some of the key responsibilities may be shared across these roles.

The Frailty Team Care Co-ordinator is a vital role within the PCN Frailty Team to proactively identify and 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 Frailty Team 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.

Cheltenham Peripheral PCN is made up of Cleevelands Medical Centre, Leckhampton Surgery, Sixways Clinic, Stoke Road Surgery and Winchcombe Medical Centre.

You will work across our 5 GP Practices who collectively care for 54,000 patients.

The PCN is determined to meet the challenges of modern primary care by working innovatively and growing our multi-disciplinary team to a holistic approach to our patient population. The PCN team already includes;
Social Prescribing Link Workers, Care Coordinators, GP Assistants, Clinical Pharmacists, Pharmacy Technicians, Newly Qualified GPs and Mental Health Nurses.

Key Responsibilities

Case Identification:

• Support the Frailty Nurse as required to undertake digital risk stratification
• Transpose data onto our clinical systems, ready to enable care coordination

Holistic Assessment:

• Support the Frailty Nurse to triage potential patients to determine who receives an assessment
• Support the Frailty Nurse to determine what action to take with those patients who do not receive an assessment, including ensuring actions are undertaken
• Contribute to the completion of the assessments as determined by the Frailty Nurse, inputting the information gained into a digital template

Personalised Care and Support Planning:

• Ensure each patient who has an assessment has a Personalised Care and Support Plan 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 an assessment

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 personalised care and support plan
• Use and be fully responsible for the care coordination function of our clinical systems 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 personalised care and support plan, escalating issues if required to the Frailty Nurse

Continuity of Care including Review:

• Be responsible for ensuring each patient who has an assessment has their plans 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 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 Nurse, provide leadership and 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 coordination and navigation across services, helping to ensure people and their carers receive a joined-up service and the appropriate support from the right…