Elderly & Frailty Care Co-ordinator

5 months ago

Cheltenham, United Kingdom St Paul's Primary Care Network Full time

**Care Coordinators play an important role within our PCN working closely with our GP practice teams, our PCN multi-disciplinary teams and wider health and social care and community colleagues.**

They identify and manage a caseload of specific patients, making sure that appropriate support is made available to them and their carers. This is achieved by bringing together all the information about a person’s 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. Care coordinators will set up and co-ordinated MDT meetings and be the point of contact for the team. They will be involved with risk stratification, data searches, monitoring and evaluation of services.

The key responsibilities of the role are outlined below:

- Provide coordination and navigation for people and their carers across health and care services, alongside working closely with our Social Prescribing Link Workers, Respiratory Team, Frailty Nurse 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. This will mainly be elderly frail patient’s and those with a history of falls.
- Lead the organisation, coordination and delivery of MDTs within the PCN - including producing the agenda and taking minutes.
- Attend the MDTs, 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
- Bring together a person’s identified care and support needs and explore their options to meet these into a single personalised care and support plan
- 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.
- Provide admin support to the Social Prescribing team including supporting with low level investigations and form completion.
- Raise awareness within the PCN to shared decision making and decision support tools

**Job Type**: Part-time
Part-time hours: 16 per week

**Salary**: £12.00 per hour

**Benefits**:

- Free parking
- On-site parking

Schedule:

- Monday to Friday

Ability to commute/relocate:

- Cheltenham: reliably commute or plan to relocate before starting work (required)

Work Location: In person

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