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.

• 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.

Arbennek PCN & INT is located in the central ICA within the Cornwall and Isles of Scilly Integrated Care System and has approximately 32,453 peopleregistered from 4 GP Practices Brannel Surgery, Clays Surgery, Probus Surgery and Roseland Surgeries.

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-disciplinary teams (MDTs) within the INT and PCN to deliver effective, co-ordinated and personalised 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 management and 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 excellent organisational and communication skills, be flexible in their approach, able toexercise initiative and demonstrate consistently high standards of professionalism. 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 records and 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 best practice, based on what matters to the person.

Todevelop and support patient Treatment Escalation Plans (TEPs) and Advanced Care Planning (ACP).

Help patients to manage their needs by answering queries, assisting with making/managing appointments, and ensuring that patients have…