Frailty Care Coordinator​/Health & Wellbeing Practitioner

DAD PCN have an exciting, opportunity for a Frailty Care Coordinator/Health & Wellbeing Practitioner to join our Primary Care Network. The role will primarily involve assisting our 6 GP practices across the locality with a caseload of housebound frail patients. This post will also work with community services and practices to promote the National cancer screening uptake in Denton and Droylsden.

The role involves working very closely with the practices and the multidisciplinary team (MDT) within the PCN.

The role is pivotal in ensuring all residents receive the best possible care and service. The role will support the PCN team in coordinating all key activity including access to services, advice, and information, and ensuring health and care planning is timely, efficient, and patient-centred.

The role involves working in the community providing proactive clinics to targeted patients in conjunction with the PCN/practice teams

The postholder will engage in positive, empathetic conversations with residents, families, and carers to identify needs and support the development, implementation, and regular review of personalised care plans. Care plans will be communicated to GPs and relevant professionals and uploaded to appropriate care records using SNOMED coding.

Working within a PCN, the postholder will proactively support people, including the frail, elderly, and those with long-term conditions, coordinating care across health and social services. They will manage a patient caseload in close collaboration with GP teams, acting as a central point of contact for patients and carers.

The role involves regular liaison with multidisciplinary teams, participation in MDT meetings, escalation of concerns to named clinical contacts, and identification of safety issues or additional support needs. The postholder will contribute to quality health outcomes and undertake clinical tasks as appropriate to training, including blood pressure monitoring, phlebotomy, and chaperoning.

They will follow agreed clinical protocols, recognise and report changes in patients conditions, maintain accurate patient records, and work effectively as part of a multidisciplinary team, liaising with colleagues and patients as required.

Denton Primary Care Network is a collaboration of the primary care teams based at 3 Denton general medical practices - Millgate Healthcare Partnership;
Guide Bridge Medical;
Denton Medical Practice, and 3 Droylsden based general medical practices:
Market Street Medical, Droylsden Medical and Medlock Vale Medical Practice. We currently have a PCN population of approximately 52,000 patients and the PCN staff work in conjunction with the local general practices to support both local and national priorities working closely with our local care homes, housebound and most vulnerable patients. If you would like a new challenge in the Community and aspire to ensure the health and wellbeing of patients, then this role may be for you

The postholder will be able to participate in positive, empathetic and responsive conversations with residents and their family and carer(s) about their needs.

Support people to develop and implement personalised care plans. Review and update personalised care and support plans at regular intervals.

Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes.

The postholder will play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services. They work closely with GP teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers.

The role will involve regularly liaison with the range of multidisciplinary professionals and colleagues involved in the residents care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported.

Actively participate in multidisciplinary team meetings in the PCN as and when appropriate identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.

Carry out and co-ordinate quality health outcomes.

This may include but not exclusively the following based on training and experience:

Blood pressure monitoring

Phlebotomy

Act as a chaperone if required.

Undertake activities identified by the clinical team in accordance with agreed written protocols.

Understand when to report changes in a patients condition.

Make clear & accurate entries into a patients records when…