PCN Frailty Care Co-ordinator

Aspen Medical Practice Primary Care Network are seeking a Frailty Care Co‑ordinator to join our well‑established Frailty Team. This exciting new post will offer applicants the opportunity to improve the lives of our patients who are living with frailty and dementia.

We are looking for someone with a passion for working with frail and/or elderly patients and those living with dementia. An empathetic and sensitive communicator who understands their own limitations and works well within a team.

Previous experience of working in a patient‑facing setting within health or social care is essential. We are seeking applicants with strong interpersonal skills, who is an excellent communicator and is able to work both alone and alongside a team.

A full UK driving licence and access to a vehicle is essential for travel either between sites or to patients’ homes.

This role will involve some administration and working alongside our newly formed dementia diagnosis MDT.

The role is available for participants who are seeking to work 25 to 37.5 hours.

Interviews for this post will take place on 27/01/2026 and invites for interview will be sent 20/01/2026 to successful applicants.

The Frailty Care Coordinator is an essential member of Aspen’s Frailty Team, responsible for proactively identifying and supporting individuals living with moderate to severe frailty and/or dementia. The postholder will ensure that patients receive co‑ordinated, person‑centred care and are able to navigate health, social care and community services effectively.

In this role, the postholder will act as a point contact for patients and their carers, providing guidance, facilitating access to appropriate support, and helping individuals understand and manage their conditions. The Frailty Care Coordinator will also ensure that any changes in a patient’s needs are recognised, communicated and responded to promptly.

The postholder will act as a main point of contact for patients, carers and health professionals either by telephone, email or face‑to‑face. They will work alongside GPs and other members of the practice team as well as a range of other health, social and community teams and partners to ensure seamless care and communication. The postholder will give advice and signpost to other services but also seek advice from their team or other members of the practice when needed.

This role is vital in helping deliver high‑quality, seamless care to some of the most vulnerable members of the community.

Aspen Medical Practice is a large, single‑practice Primary Care Network (PCN) serving just over 32,000 patients. We operate from one modern main surgery, supported by two branch sites, and work together as one cohesive, integrated team. This role will be primarily based at our main site.

Aspen Medical Practice has a higher‑than‑average proportion of older and frail patients, and we have developed a strong, well‑established Frailty Team to meet their needs. The team currently consists of two Frailty Matrons and two Social Prescribers, all working collaboratively to deliver high‑quality, person‑centred care.

By joining us, you will become part of a dedicated and experienced team with a genuine passion for supporting the local frail population and enhancing their health, wellbeing and overall quality of life.

Key responsibilities include:

• Frailty case identification
• Managing own caseload
• Holistic assessment of patients with frailty or at risk of frailty
• Providing frail patients with personalised care and support plans
• Working with a wide range of other professionals, carers and patients to provide safe and effective care
• Responsibility for arranging and providing administration support for the dementia co‑diagnosis model.
• Maintaining accurate, up‑to‑date records in line with practice and PCN requirements.
• Providing general administrative support to the Frailty Team as required.

• Good standard of education with minimum 5 GCSEs or equivalent.
• Good IT skills – ability to use MS Office (Word, Excel, Outlook, PowerPoint) to a good standard.
• Full UK Driving Licence
• Care Planning and Coordination qualification
• Edu…