Frailty Care Navigator Inner PCN

We are searching for a Frailty Navigator to join our Inner City PCN team.

You will be required towork across various locations in Gloucester. This will also include our Inner City PCN Surgeries Gloucester Health Access, Pavilion and St James Family Doctors, Severnside Medical Practice and Kingsholm Surgery .

Working Hours:18.5 hours per week.

Interview date: Thursday 19thFebruary TBC

Applications may close early depending on response.

To proactively identify andwork with people living with moderate or severe frailty and/or dementia toprovide co-ordination and navigation of care and support across health, careand support services.

The Care Navigator will actas 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.

Provide administrative support, working for the benefit of patients, providing and maintaining high standards of care for patients health needs.

The post holder will become an integral part of the PCN multidisciplinary team, working alongside social prescribing link workers and other community providers toprovide an all-encompassing approach to personalised care.

The role is intended to support the Clinical Director and Business Manager to develop thePCN and achieve the PCN DES targets, undertaking a variety of projects and supporting digital transformation as required.

The job is primarily working with practices in the PCN and you will be required to travel independently between practices and occasionally G DOCs offices in Gloucester,and to attend meetings etc., hosted by other agencies throughout

Gloucestershire.

Reports to: the PCNBusiness Manager and the PCN Clinical Director.

Line Manager: PCN Business Manager

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

We directly manage several GP surgeries in Gloucester and 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 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 acrossthe local health system.

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

Duties

Assist practices to identify and work with frail/elderly people and their carers, to provide coordination and navigation of care and support across health and care services.

Case Identification:

Support the Frailty Practitioner as required to undertake digital risk stratification

Transpose data onto the Personalised Proactive Whiteboard (PPW), readyto 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:

oEnsure each patient who has a CGA has aPersonalised 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

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

General

Identify carers and help them access services to support them, ensuring they are codedas 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 healthand wellbeing.

Work closely with GPs and practice teams to support them to manage patients to develop individual personalised care and support plans, ensuring appropriate support is made available to patients and carers,helping them to understand and manage their condition and ensure changing needsare addressed.

Review patients needs and help them access the services and…