Job Description

The role involves working closely with our Frailty Care Practitioners, Health and Wellbeing Coaches and Frailty Matrons along GPs, Practice Managers and other primary care professionals within the PCN to support the hub and proactively support delivery of the comprehensive model of care to patients with frailty. Coordinate our Frailty Care Team caseload to ensure referrals from our five practices are prepared for the allocation meeting and booked with the most appropriate frailty care team member to bring together a patients identified care and support needs ensuring timely support and coordination. Provide administrative resource and support to the Frailty Care Team, processing requests and maintaining accurate records using our two clinical systems SystmOne and EMIS and monitoring tools. Provide coordination and navigation for people and their carers across health and care services, alongside working closely with Frailty Care Team Clinicians, PCN Practices, Neighbourhood locality teams, Social Prescribing Link Workers, Care Coordinators, Clinical teams and third sector services.



Support data reporting and analysis including developing and presenting reports. Take an active role in MDTs to help coordinate care for patients with frailty and long term conditions keeping accurate minutes and updating patient records. Produce the care home ward round planning list liaising with care home staff on a weekly basis. Support the coordination and delivery of MDTs participating in the development of Enhanced Care in Care Homes DES liaising with PCN Leads to agree and co-ordinate visit schedules, working with home within the Network to ensure patients are correctly registered with the appropriate practice.



Specific project work liaising with Frailty Team leads on implementation of shared process, and collaboration opportunities to support improved patient care. Support communications with our member practices to raise awareness of the Frailty Care Team, Enhanced Access Programme and Education events and its range of support offers. Coordinate meetings and presentations as required. Produce appropriate support documentation and literature for a variety of audiences from professionals to patients.



Collation of agendas, production of minutes / action logs for PCN / MDT meetings and ensure all actions are completed including follow up if necessary. Collation and management of shared documents on the appropriate platform ensuring the latest versions are available and is made available in a timely manner. Data collection and activity reports for Enhanced Access Clinics (EA) Managing computer rotas and ledgers for ARRS team Providing support with rota filling and booking templates for Enhanced Access Clinics Coordinating follow up from EA appointments where required Coordinate collection of patient satisfaction data from EA clinic attendance Please see attached job description for full details of the role.