Frailty Care Navigator Inner PCN

We are searching for a Frailty Care Navigator to join our Inner City PCN team. You will be supporting the Frailty Practitioner to identify frail patients on the GP systems and to make sure they get the support they need.

This position would be suitable for the right candidate that is willing to learn and is interested in working with older people.

You will be required to work across various locations in Gloucester. This will include our Inner City PCN Surgeries Gloucester Health Access, Pavilion and St James Family Doctors, Severnside Medical Practice and Kingsholm Surgery.

Working Hours:18.5 hours per week.

Interview date:Thursday 12th March TBC

Applications may close early depending on response.

To work with the Frailty Practitioner to use the GP systems to identify people living with moderate or severe frailty to ensure they get the care and support they need.

To send out questionnaires to patients and ensure we get a response by following up on forms that aren't returned.

To act as a central point of contact for people and their carers.

To provide administrative support for the Frailty Practitioner and the Frailty Project.

To work with social prescribers and community providers to ensure people are signposted to the right support.

The job is primarily working with practices in the PCN and you will be required to travel independently between practices and occasionally G DOCs offices in Gloucester, and to attend meetings etc., hosted by other agencies throughout Gloucestershire.

Reports to:the PCN Business Manager and the PCN Clinical Director.

Line Manager:PCN Business Manager

G DOC LTD is a unique, GP-owned organisation all GP surgeries in Gloucestershire are our shareholders. We operate with an for-profit ethos, ensuring every decision and service is focused on improving patient outcomes and reinvesting in local Primary Care across the county.

We directly manage several GP surgeries in Gloucester and the Forest of Dean, providing patient-centred care to more than 45,000 patients. We value continuity of care and practice teams are at the heart of all we do. In addition to our surgeries, we deliver a range of countywide commissioned services designed to improve access, increase capacity, or provide specialist support. Our teams are committed to delivering sustainable, high-quality primary care while fostering innovation and collaboration across the local health system.

By joining us, you'll be part of an organisation that puts people first supporting staff wellbeing, professional development, and a collaborative culture. You'll benefit from the stability, support, and career opportunities of a larger organisation, while still working in close-knit, community-focused teams.

Duties

Assist practices to identify and work with frail/elderly people and their carers, to provide coordination and navigation of care and support across health and care services.

Case Identification:

Support the Frailty Practitioner as required to undertake digital risk stratification

Transpose data onto the Personalised Proactive Whiteboard (PPW), ready to enable care coordination

Support the Frailty Practitioner to triage potential patients to determine who receives a Comprehensive Geriatric Assessment (CGA)

Support the Frailty Practitioner to determine what action to take with those patients who do not receive a CGA, including ensuring actions are undertaken

Contribute to the completion of CGAs as determined by the Frailty Practitioner, inputting the information gleaned into a digital template

Personalised Care and Support Planning:

As determined by the Frailty Practitioner:

oEnsure each patient who has a CGA has a Personalised Care and Support Plan (PCSP) that has been discussed and finalised with the patient and any carer/family; this will help to manage their needs and achieve better health and wellbeing outcomes

oEnsure a ReSPECT plan is completed for each patient who has a CGA

General

Identify carers and help them access services to support them, ensuring they are coded as a carer on the GP clinical system if they are a patient at the Practice

Provide a single point of contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care.

Assist people to access self-management education courses, peer support, health coaching and other interventions to enable them to better manage their health and wellbeing.

Work closely with GPs and practice teams to support them to manage patients to develop individual personalised care and support plans, ensuring appropriate support is made available to patients and carers, helping them to understand and manage their condition and ensure changing needs are addressed.

Review patients needs and help them access the services and support they require to understand and manage their own health and wellbeing

Liaise and work with the ICB, practices, voluntary and other…