LS25 / 26 PCN Proactive Frailty Care Coordinator

The Care Coordinator role is seen as a critical and evolving post to support [the Enhanced Health in Care Homes (EHCH) Multi-Disciplinary Teams within the locality to deliver effective, coordinated care for vulnerable and frail adults, particularly those at high risk of a hospital emergency admission, ED attendances or out of hours care.To proactively coordinate personalised care and support planning for the most vulnerable people in the community, focussing on the frail/elderly and those with other long-term health conditions.

To meet with people, families and carers (in the practice, in their home and in other community settings) to co-ordinate their care, review their needs and help them access the services and support they require, assisting them to understand and manage their own health and wellbeing referring to other professionals where appropriate.

Main duties of the job

Act as a central point of contact to ensure that patients receive the best possible care, and the person is supported to achieve the outcomes that are important to them. This is achieved by bringing together all the information about a persons identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.

To support people in preparing for or following-up clinical conversations they have with primary care professionals to enable them to be actively involved in managing their care and supported to make choices that are right for them. You will use knowledge of health and social services available in the locality, including those offered by the community and voluntary sector, to link people up with these and help them overcome any barriers they might encounter. The aim is to help people improve their quality of life and avoid unplanned hospital admissions.

The Care Coordinators role will support the frailty team and Multi-Disciplinary Team in coordinating all key activity including access to services, advice, and information, helping them to live well at home. This role will also include some clinical aspects, such as observations, venepuncture, skin checks etc.

LS25/26 PCN has a patient population of approximately 77,500 across 7 practices. We aim to provide high quality services adhering to principles of best practice, promoting equal opportunities, and working positively with diversity.