PCN Frailty Care Coordinator

Job Summary

North and South Gloucester Primary Care Network seek a dedicated Frailty Care Coordinator to join our growing Living Well Team. This new role offers a unique opportunity to make a real difference in the lives of the ageing population within our community. The role will work closely with our Living Well Team’s Frailty Administrator and will be scheduled for 30 to 37.5 hours per week, to be agreed with the successful applicant.

• Provide coordination and navigation for people and their carers across health and care services, working closely with the Living Well Team (Social Prescribing Link Workers, Frailty Nurses, Care Coordinators) and all primary care team members.
• Act as a first point of contact for patients, carers and professionals, handling queries by telephone, e‑mail or in person in a calm and sensitive way, providing advice and ensuring issues are followed up promptly.
• Identify and manage your own caseload of patients, carrying out home visits to complete or review Personalised Care Plans (e.g., Me @ My Best, What Matters to Me), and undertake dementia reviews (training provided).
• Help people manage their needs through answering queries, making and managing appointments, and ensuring they receive high‑quality written or verbal information to help them make choices about their care.
• Work sensitively with patients, families and carers to improve understanding of the patient’s condition and support them in developing and reviewing personalised care and support plans to achieve better health outcomes.
• Proactively identify a cohort of people needing anticipatory coordinated support using local knowledge and population health data.
• Contribute to local Multi‑Disciplinary Team meetings within the Network and follow up actions within defined timescales.
• Collate relevant information and ensure accurate documentation and sign‑posting in line with NHS policies and confidentiality standards.
• Maintain accurate and up‑to‑date patient and service records, including inputting data into electronic systems (e.g., EMIS, Systm One or local databases).
• Assist with the management of the Living Well Team’s recall system, ensuring patients are coded appropriately and followed up in a timely manner.
• Assist with distribution of Health and Wellbeing Self‑Assessment questionnaires, ensuring responses are recorded accurately and any necessary follow‑up actions are completed.
• Assist in the preparation of patient information, resources and communication materials.
• Liaise with internal and external stakeholders, including healthcare professionals, local authorities and voluntary sector organisations.
• Contribute to the continuous improvement of administrative and care coordination processes to enhance efficiency and patient experience.

• Good standard of education with 5 GCSEs or equivalent.
• Good IT skills, especially a working knowledge of MS Office (Word, Excel, PowerPoint, Outlook).
• Commitment to continuing professional development, including the Personalised Care Institute course(s).
• Full UK Driving Licence.

• Further education qualifications or Degree level education.
• Training in health coaching/motivational interviewing or equivalent.
• Knowledge of Systm One/EMIS Patient Clinical Systems.

• Excellent interpersonal and communication skills.
• Ability and confidence to handle difficult conversations.
• Ability to structure conversations using a coaching approach based on what matters to the person.
• Ability to talk to a wide range of professionals appropriately.
• Ability to nurture key relationships and maintain networks.

• Proven experience in a similar role, ideally within healthcare or social care settings.
• Excellent communication skills, both verbal and written, with a professional, empathetic and approachable manner.
• Ability to explain complex information clearly to patients, carers and professionals.
• Use of coaching techniques to empower patients and carers.
• Ability to manage own caseload of patients.
• Commitment to improving the quality of life for older people.
• Ability to build positive relationships across health and social care partners.
• Excellent…