Job Description

Job summary

The Frailty care co-ordinator will support the proactive identification, prevention and management of frailty across the Heatons PCN population. The postholder will provide holistic assessments and personalised wellbeing planning that empower patients to remain independent and improve their quality of life.

Working closely with the PCN's multidisciplinary teams, community partners and care homes, the role will contribute to reducing falls, avoidable hospital admissions, and inequalities in health outcomes.

Main duties of the job

Undertake holistic assessments of physical, emotional, social and environmental needs. Manage caseloads from practices and new referrals. Perform blood pressure checks and venepuncture where trained. Educate patients to recognise early signs of deterioration to prevent crises and admissions. Address nutrition, hydration, home safety, mental wellbeing, social isolation and financial security. Support care homes with falls prevention, mobility and wellbeing reviews. Work with multidisciplinary teams, secondary care, local authority and voluntary services to ensure continuity of care. Comply with governance, safeguarding, confidentiality and data protection.

Job description - Job responsibilities

Clinical and Functional Skills

Undertake comprehensive holistic assessments that are typically 60 to 90 minutes, exploring physical, emotional, social and environmental needs Manage a defined caseload from each practice plus new referrals generated from triage lists, frailty registers and LCS Falls & Fractures data Perform blood pressure checks and venepuncture where trained and delegated Carry out falls risk assessments Educate and empower patients to recognise early signs of deterioration or mobility changes preventing crisis episodes and hospital admissions Contribute to proactive health screening and lifestyle interventions including bone health, hydration, nutrition and physical activity promotion

Holistic Wellbeing

Provide person centred care to support self management goal setting and positive behaviour change Address key wellbeing determinants including nutrition, hydration, home safety, mental wellbeing, social isolation and financial security Initiate advance care planning discussions and promote the use of tools to record preferences and wishes Signpost or refer patients to appropriate internal or external services including social prescribers, dementia support, welfare advice, community groups, podiatry or dietetics Actively contribute to digital inclusion supporting patients and carers to use technology for health monitoring appointments and social connection Provide support to patients on the gold standards framework register contributing to proactive end of life care planning

Collaborative and System Working

Work as an integral member of the primary care network multidisciplinary team Collaborate with secondary care, local authority and voluntary sector organisations to ensure seamless support and continuity of care Contribute to the development of frailty pathways, population health initiatives and service evaluation within the primary care network Maintain accurate and timely documentation using approved clinical systems Act as a community connector strengthening relationships between health care and community assets to build resilience and reduce dependency on clinical services Share learning and insight across the PCN to support proactive care planning, digital innovation and continuous improvement

Person Specification

Experience

Essential

Experience of working both autonomously and as part of a multidisciplinary team in a health, social care or community setting. Experience in communicating effectively with a wide range of people, including patients, carers, and health and social care professionals.

Desirable

Experience within a Primary Care Network or NHS frailty programme Experience working in care homes or with housebound patients Experience of working with older adults including those with dementia, frailty or at risk of falls Experience in using care planning templates

Qualifications

Essential

GCSE or equivalent English and Maths Grade C/4 or above Full UK driving licence and access to a vehicle for home and care home visits

Desirable

Additional training in frailty, falls prevention, dementia care or occupational therapy assistant skills Digital health tools or telehealth training

Knowledge / Skills / Attributes

Essential

Excellent communication and interpersonal skills Ability to motivate and empower patients Strong organisational and time management skills; able to manage own caseload IT literacy - Microsoft Office, EMIS/SystmOne or similar systems Understanding of frailty, ageing, falls risk and social determinants of health Awareness of safeguarding and confidentiality principles

Desirable

Knowledge of the Rockwood Frailty Scale, Advance Care Planning and NHS Personalised Care frameworks Familiarity with local community and voluntary sector resources

Personal qualities

Essential

Compassionate, patient-centred and non-judgemental Proactive and self-motivated, with the ability to work independently and collaboratively Adaptable to evolving PCN and service priorities

Desirable

Ability to contribute to service innovation, training or peer support

Additional information

The role requires flexibility across all Heatons PCN practices and care home settings. The post is subject to an enhanced DBS check. The job description and person specification will be reviewed annually to reflect service development and PCN priorities.

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Job Type: Full-time

Pay: 27,485.00-30,162.00 per year

Benefits:

Company pension Employee discount
Work Location: In person