Frailty Care Coordinator

Arbennek PCN is looking for an innovative and highly motivated person to join its team as a Frailty Care Coordinator. The Frailty Care Coordinator role is seen as acritical and evolving post to support the development of a proactive frailtyservice operating at Integrated Neighbourhood Team (INT) level. We will be holding interviews for shortlisted candidates on 21.07.26. Our default position for a selection/assessment interview is face to face. The interview date and venue are communicated within our Job Advertisement to ensure that candidates can adequately plan attendance if invited for interview. We welcome and invite any requests for adjustments in the selection process, in particular for any needs connected with disability, and/or language. We ask that any adjustments are requested in good time so that they can be considered and properly planned for. We may agree to a virtual meeting as a reasonable adjustment for disability. We do not permit or in any way consent to the covert recording of any interview (whether audio and/or video). We also do not permit the use of AI or similar software to prompt responses during an in interview and where we have reasonable belief that such tools are being used, we will cease the interview, and your application will not proceed any further. Main duties of the job * Proactively identify and work with a cohort of patients to support their personalised care requirements * Provide coordination and navigation support using digital tools to help patients access appropriate services * Develop and maintain personalised care and support plans based on an individuals needs and what matters to them. * Promote preventative heath care and continuity of care. About us Arbennek PCN & INT is located in the central ICA within the Cornwalland Isles of Scilly Integrated Care System and has approximately 32,453 peopleregistered from 4 GP Practices Brannel Surgery, Clays Surgery, Probus Surgeryand Roseland Surgeries. Job responsibilities Job Purpose The Frailty Care Coordinator role is seen as acritical and evolving post to support the development of a proactive frailtyservice operating at Integrated Neighbourhood Team (INT) level. The Frailty Care Coordinator will support multi-disciplinaryteams (MDTs) within the INT and PCN to deliver effective, co-ordinated andpersonalised care for patients in care homes and for a cohort of elderly andfrail patients. The post holder will work closely with themulti-disciplinary team to support INT and PCN on-going patient case managementand to support patient cohorts which have been identified for support by theINT and PCN. This will involve working with the GP surgeries and linking inwith a range of community health and social care services, care homes, the VCSEand third party services. The post holder will demonstrate excellentorganisational and communication skills, be flexible in their approach, able toexercise initiative and demonstrate consistently high standards ofprofessionalism. The post holder must at all times be aware of the need forconfidentiality and integrity. They will also need a basic knowledge of Healthand Social Care terminology and eligibility criteria and current teamstructures and pathways. Key working relationships Frailty GP lead Patients, patients families and carers GPs, nurses and other practice staff Care home managers, clinicians, carers and staff Frailty GP Lead, Case Manager and Geriatrician Community nurses and other allied health professionals Community pharmacists and support staff Responsibilities underpinning the role To assist the team to develop one single personalisedcare and support plan for patients to be held on the patients medical recordsand in the care homes. Holistically bring together all of a patientsidentified care and support needs, and explore options to meet these with asingle personalised care and support plan (PCSP), in line with PCSP bestpractice, based on what matters to the person. Todevelop and support patient Treatment Escalation Plans (TEPs) and Advanced CarePlanning (ACP). Helppatients to manage their needs by answering queries, assisting with making/managing appointments, and ensuring that patients have good verbal or writteninformation to help them make choices about their care. Providecoordination and navigation for patients and their carers across health andsocial care services, working closely with social prescribing link workers andother primary care professionals. Explore and assist people to access personalhealth budgets or appropriate benefits where eligible. Supportpatients to utilise decision aids in preparation for a shared decision-makingconversation. Workwith GPs and other primary care professionals and colleagues within the INT andPCN to identify and manage a caseload of patients, and where required and asappropriate, refer patients back to other health professionals within the INT. Raiseawareness within the INT of shared decision making and decision support tools.Raise awareness of how to identify patients who may benefit from shareddecision making and support INT staff and patients to be more prepared to haveshared decision-making conversations. To act as first point of contact for professionals,GPs, care homes, community services and the third sector across the INT. Responsible for the organisation of MDT meetings and supportingthe coordination and delivery of MDTs within the INT and PCN. Responsiblefor a register of patients identified at INT MDT coordinating patient careacross services and the INT. Reviewdischarge summaries and conduct post discharge follow up call to review patientsneeds and arrange a package of care if needed. Managethe recall of patients in need of bloods/BPs and other diagnostic test formedication reviews and/or green eclipse alerts supporting with patientobservations where necessary. Toact as a support contact for elderly and frail patients. Tosupport end of life care and palliative care. Toprovide support for patients with learning disabilities. Tofollow appropriate safeguarding procedures. Toundertake patient observations blood pressure, venepuncture, bodytemperature, respiratory rate and oxygen saturation. Tosupport housebound and care home patients with ability to independently travelessential in role delivery. Administrative Reponsibilities To work as a key member of the MDT to help support thedevelopment of effective MDT meetings. Totake a lead in IT ensuring all MDT staff have access to Microsoft Teams andhave adequate equipment to participate in video meetings. Lead on the IT facilitation of the MDT meetings usingMicrosoft teams including sending out invites to appropriate members of theMDT. To take minutes of MDT meetings and ensure that actionpoints identified are recorded and followed up within a set timescale. Under guidance from their line manager take initiativein the organisation and administration of MDT working to minimise the demandsupon the multidisciplinary team. To work with the wider MDT to identify appropriate casemanagers* for high-risk patients to ensure that patients are reviewed, andanticipatory care plans are developed Ensure that all patients Anticipatory Care Plans,diagnostics results and associated correspondence are available to the MDT,liaising with all agencies as appropriate, accessing IT systems to ensurerelevant information is available To liaise with acute hospitals and coordinate thesharing of key information between the acute hospital teams and the MDT team. Actas a non-clinical contact for the care home to assist with case management ofpatients at risk of admission; working with the ANP / GP to identify sources ofsupport in liaison with case managers. Toaccurately read code and update/maintain patients records for anticipatorycare. Toupdate care plan templates within Systm1 ensuring accuracy with read codesused. Maintainan accurate record of two week wait referrals for practice audits. Toprovide support with safeguarding admin (adults and child). Under the guidance of case managers assist with thedischarge process to reduce length of stay in the acute / community hospitalsetting This list is not exhaustive and may be subject to change Workforce Responsibility The post holder must remain up to date with mandatorytraining as required The post holder will be required to drive The post holder may be required to undertake duties atany location in the community in order to meets service needs Concentration required for data analysis, trackingpatients and meetings, frequent interruptions requiring attention andre-prioritisation of work Input data for a significant period Arbennek Healthcare is committed to an equal opportunities policythat affirms that all staff should be afforded equality of treatment andopportunity in employment irrespective of sexuality, marital status, race,religion/belief, ethnic origin, age, or disability. All staff are required toobserve this policy in their behaviour to fellow employees. Confidentiality All employees are required to observe the strictest confidencewith regard to any patient/client information that they may have access to, oraccidentally gain knowledge of, in the course of their duties. All employees are required to observe the strictest confidenceregarding any information relating to the work of Arbennek Healthcare and itsemployees. You are required not to disclose any confidential information eitherduring or after your employment with Arbennek Healthcare, other than inaccordance with the relevant professional codes. Failure to comply with these regulations whilst in the employmentof Arbennek Healthcare could result in action being taken. Data Protection All employees must adhere to the Arbennek Healthcare Policy on theProtection and use of Personal Information, which provides guidance on the useand disclosure of information. The practices of North Cornwall Coast also havea range of policies for the use of computer equipment and computer-generatedinformation. These policies detail the employees legal obligations and includereferences to current legislation. Health and safety Arbennek Healthcare expects all staff to have a commitment topromoting and maintaining a safe and healthy environment and be responsible fortheir own and others welfare. You will be responsible for adopting the risk management cultureand ensuring that you identify and assess all risks to your systems, processesand environment and report such risks for inclusion within the risk register ofthe practices of Arbennek Healthcare. You will also attend mandatory andstatutory training, report all incidents/accidents, including near misses, andreport unsafe occurrences as laid down within the Incidents and AccidentsPolicy. Other duties The above job description is designedto give an overview of the tasks and responsibilities for this position; it isnot intended to be exhaustive. The Strategic Manager will meet annually withthe post holder to review and ensure that this position remains relevant and inaccordance with the evolving needs of the PCN. Person Specification Qualifications * Qualified NVQ level 2 (or equivalent) Health and Social care * Qualified NVQ level 3 (or equivalent) Health and Social care * Minimum of 2 years experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field * Experience of administrative duties * Computer literate and proficient in the use of Microsoft packages and other software. * Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality. * Able to prioritise and manage own workload * Excellent verbal and written communication * Experience of taking Patient observation e.g. blood pressure, venepuncture, body temperature, respiratory rate and oxygen saturation * Able to deal with service users sensitively * Able to work as part of team * Strong analytical and judgement skills. * Experience providing signposting and advice * Conscientious, hardworking and self-motivated to work with minimal supervision * Professional attitude and assertive approach * Committed to development both personally and for the organisation * Ability to meet deadlines and work under pressure * Experience of developing and supporting PCSPs, TEPs and ACPs * Experience of arranging meetings/ minute taking * Understanding of health and social care processes * Experience of working with a Trauma led approach 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. 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