Job Description

Main Roles & Responsibilities:

With the support of the Primary care team proactively identify patients who may be frail and would benefit from input

Manage and prioritise a caseload, in accordance with the health and wellbeing needs of their population through taking an approach that is non-judgemental, based on strong communication and negotiation skills, while considering the whole person when addressing existing issues.

Provide personalised support to individuals, their families, and carers to support them to be active participants in their own healthcare; empowering them to manage their own health and wellbeing and live independently. Coaching and motivating patients through multiple sessions to identify their needs, set goals, and supporting patients to achieve their personalised health and care plan objectives; providing interventions such as self-management education and peer support.

Supporting patients to establish and attain goals that are important to the patient and supporting personal choice and positive risk taking while ensuring that patients understand the accountability of their own actions and decisions, thus encouraging the proactive prevention of further illnesses.

Utilise health coaching skills to support individuals to develop the knowledge, skills, and confidence to manage their health and wellbeing, whilst increasing their ability to access and utilise community support offers and work in partnership with social prescribers to achieve this.

Undertake Frailty Assessments/Comprehensive Geriatric Assessments, falls assessments using the next steps with the STOPP START criteria.

Work in partnership with patients to support them to develop their level of knowledge, skills and confidence enabling them to engage with their health and well-being and subsequently supporting them in shared decision-making conversations.

Ensure all relevant patient information, including historical information, compliance issues, long term conditions are managed, and symptoms are provided and escalated appropriately

Work with primary care team to organise direct referral to their services where beneficial to the patient

Co-ordinating Stockport Integrated Pharmacy Service team/medicines optimisation within the community where necessary including arranging annual medication reviews

To work alongside digital services providers to enable electronic care planning when developed/implemented

To support clinical teams with advanced care planning/end of life care planning as appropriate

To assist with validation of and communication with people registered under a lasting power of attorney

To support with the Palliative Care register and attend meetings

To develop collaborative relationships and work in partnership with social prescribing link workers, care coordinators, and other primary care roles within the practice and wider PCN.

Adhere to legislation, policies, procedures and guidelines both local and national.

Regularly attend workplace and staff engagement meetings and contribute positively to discussions about the improvement of care

Job Types: Part-time, Permanent

Pay: 20,000.00-25,000.00 per year

Expected hours: 20 - 25 per week

Schedule:

Monday to Friday
Work Location: In person

Application deadline: 15/08/2025