Pcn Frailty Care Co-ordinator

**JOB TITLE**:PCN Frailty support coordinator**

**REPORTS TO: PCN Lead OT**

**ACCOUNTABLE TO: PCN Clinical Director**

**WAGE: £22,815 - £25,545 Per Annum pro-rota**

**HOURS: 18 hours per week**

**JOB SUMMARY**:
An exciting opportunity has arisen for a Care Coordinator to join the Mid Devon Primary Care Network (PCN).

The role will work across the Care Coordinator and Frailty Team but will be predominantly focussed on Frailty and offering early support to patients becoming increasingly frail. A key requirement is focussing on what matters most to the patients who are supported and problem solving to achieve this.

It will involve a combination of home visits, ageing well clinic support, telephone support / reviews with patients and/or their carers, liaising with the multi-disciplinary wider health and care teams and surgery MDT attendance.

The Frailty Service and Enhanced Health in Care Homes (EHCH) is an exciting new model of care being implemented by the PCN for patients across the network. It is being led by a clinical lead who you will work with closely to support the continued development of this project. The Care Home and Frailty Coordinator is an evolving post and so we are looking for an individual who is excited to share ideas and help develop the service. We recognise the value that this role brings to our practices and patients, and we look forward to growing our PCN team. As a Frailty Care Co-ordinator, as the role develops you will work closely with the practices, secondary care services, the voluntary sector, patients, and their families to ensure patients across the PCN receive the best possible care and service.

**JOB RESPONSIBILITIES**:

- Frailty Care Coordinator
- The Frailty Care Coordinator will have overall responsibility for coordinating and managing the administrative functions of care home MDT meetings, triaging Frailty service referrals including; management of new referrals and ensuring they are processed appropriately with information circulated to relevant team members, ensuring appropriate attendance at MDTs, sending out invites and relevant sensitive information, minute taking, disseminating minutes, processing recommended referrals and ensuring all actions are followed up.
- Work closely and in partnership with PCN colleagues including Social Prescribing Link Workers, Health & Wellbeing Coaches, Clinical Pharmacist(s) and Allied Health Professionals.
- Work with the EHCH clinical lead and multi-disciplinary team to help identify patients new to care homes, and those recently discharged from hospital, ensuring that they receive personalised care and support plans.
- Assist with disseminating personal care and support plans for individual patients to the patient, NOK and other relevant services.
- Work alongside the EHCH, Frailty teams and other PCN colleagues to contribute to the ongoing design and development of EHCH and Frailty services across the PCN.
- Maintain timely and accurate patient records using GP record systems and agreed read codes, pulling weekly reports to identify frail and care home residents requiring support and to maintain an up-to-date record of progress/achievement against Key Performance Indicators.
- To contribute toward positive working relationships with our care home, health and social care colleagues.
- To promote the EHCH and Frailty service.
- To undertake general office duties to support the role.
- To work effectively as part of a team to provide cover as required and to be flexible regarding working hours to meet the needs of the service.
- Work with key personnel in the PCN to develop & support collective general practice projects.
- Actively work toward developing and maintaining positive working relationships with the PCN teams including admin staff, GPs, practice managers, the clinical lead Occupational Therapist, PCN clinical director, Social Prescribers, and clinical pharmacy teams.
- Foster and maintain strong links with other services including social care, secondary care services and the voluntary sector.
- Contribute to and undertake data collection.
- Complete clinical tasks as assigned by clinicians e.g., telephone calls to patients, completing Personalised Care Plans, supporting with patient home visits.
- Complete assessments around mobility, transfers and other activities of daily living as agreed by clinicians.

**CONFIDENTIALITY**:

- In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately
- In the performance of the duties outlined in this Job Description, the post-holder may have access to confidential information relating to patients and their carers, surgery staff and other healthcare workers. They may also have access to information relating to the surgery as a business organisation. All such information