Frailty Care Coordinator - NHS
NHS Jobs Gloucester
This role will operate within the Frailty Team which forms part of our wider Living Well Team made up of Frailty Nurses, Social Prescribing Link Workers, Health and Wellbeing Coach and Care Coordinators. This is a new role for our network, expanding our Frailty Team to address the needs of our population.
Job Description The Frailty Care Coordinator will play a key role within our PCN working closely with our GP practice teams, our PCN Living Well Team and wider health and social care and community colleagues. They will act as the main point of contact for the Team, triaging incoming referrals from our member practices and signposting appropriately.
They will be responsible for setting up and co-ordinating our Multi-Disciplinary Team meetings recording and following up on agreed actions. They will be involved with risk stratification, data searches, monitoring and evaluation of services.
The Frailty Care Coordinator will also identify and manage their own caseload of patients, carrying out home visits to complete and review Personalised Care and Support Plans, Me at my Best and What Matters to Me. The key responsibilities of the role are outlined below: Act as the focal point of contact for the Team.
Triage/screen incoming referrals and signpost appropriately. Provide coordination and navigation for people and their carers across health and care services, alongside working closely with our Living Well Team (Social Prescribing Link Workers, Frailty Nurses and Care Coordinators) and all members of our primary care teams.
With the support of the Practice and Network proactively identify a cohort of people in need of anticipatory coordinated support, using local knowledge and population health intelligence. Manage the Team shared email inbox, ensuring that all messages are dealt with efficiently and any necessary actions are assigned appropriately.
Manage the Team Task inbox ensuring tasks are triaged appropriately. Lead on the organisation, co-ordination, and delivery of MDTs within the PCN including producing the agenda and taking minutes, recording and following up actions within defined timescales agreed during the meeting.
Improve continuity of care by acting as a point of contact for people, families and professionals. Identify and manage their own caseload of patients, carrying out home visits to complete/review Personalised Care and Support Plans, What Matters to Me and Me at my Best Forms.
Ensure that people have good quality information to help them make choices about their care and structure conversations using a coaching approach. Provide time, capacity and expertise to support people in preparing for or following-up on clinical conversations with health professionals.
Job Description The Frailty Care Coordinator will play a key role within our PCN working closely with our GP practice teams, our PCN Living Well Team and wider health and social care and community colleagues. They will act as the main point of contact for the Team, triaging incoming referrals from our member practices and signposting appropriately.
They will be responsible for setting up and co-ordinating our Multi-Disciplinary Team meetings recording and following up on agreed actions. They will be involved with risk stratification, data searches, monitoring and evaluation of services.
The Frailty Care Coordinator will also identify and manage their own caseload of patients, carrying out home visits to complete and review Personalised Care and Support Plans, Me at my Best and What Matters to Me. The key responsibilities of the role are outlined below: Act as the focal point of contact for the Team.
Triage/screen incoming referrals and signpost appropriately. Provide coordination and navigation for people and their carers across health and care services, alongside working closely with our Living Well Team (Social Prescribing Link Workers, Frailty Nurses and Care Coordinators) and all members of our primary care teams.
With the support of the Practice and Network proactively identify a cohort of people in need of anticipatory coordinated support, using local knowledge and population health intelligence. Manage the Team shared email inbox, ensuring that all messages are dealt with efficiently and any necessary actions are assigned appropriately.
Manage the Team Task inbox ensuring tasks are triaged appropriately. Lead on the organisation, co-ordination, and delivery of MDTs within the PCN including producing the agenda and taking minutes, recording and following up actions within defined timescales agreed during the meeting.
Improve continuity of care by acting as a point of contact for people, families and professionals. Identify and manage their own caseload of patients, carrying out home visits to complete/review Personalised Care and Support Plans, What Matters to Me and Me at my Best Forms.
Ensure that people have good quality information to help them make choices about their care and structure conversations using a coaching approach. Provide time, capacity and expertise to support people in preparing for or following-up on clinical conversations with health professionals.
Work with members of the primary care teams to develop and implement data collection systems that will provide accurate and timely data to monitor and evaluate services. Raise awareness within the PCN to shared decision making and decision support tools.
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and the only one to be endorsed as a Centre of Excellence by Skills for Care. We have over 150 branches across England and Wales and we're looking for Care Coordinators who are as passionate about what they do as we are to join our growing team.
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