Care Coordinator
3 days ago
Newcastle Central PCN is excited to launch a Frailty Pilot Service to provide proactive, person-centred support for older adults living with frailty. We are looking for an enthusiastic and compassionate Care Coordinator to join our new multidisciplinary frailty team. As Care Coordinator, you will work closely with Advanced Nurse Practitioners, GPs, social prescribers, and community teams to ensure patients with frailty receive timely, coordinated, and holistic care. You will act as a central point of contact for patients, families, and servicessupporting care planning, follow-up, and continuity across different settings, document data from assessments to facilitate identification of outcomes and ensure relevant documentation is available for the ANP and health coaches.
This is an ideal opportunity for someone with a background in health, social care, or support work who is passionate about helping older people to live well in their communities. Main Duties of the Job Proactively identify and engage patients living with frailty, using frailty tools and risk stratification. Support the coordination of care for patients, including arranging appointments, home visits, and referrals to appropriate services, check in with patients to review their progress with their action plans between formal reviews. Act as a named contact for patients and carers, ensuring they understand their care plans and know who to contact.
Liaise with internal and external services including GPs, community nursing, adult social care, mental health, and voluntary sector organisations. Help coordinate Multi-Disciplinary Team (MDT) meetings and follow up actions. Support personalised care planning and advanced care planning conversations, ensuring patient voice and choice are central. Assist with tracking and recalling patients for reviews, follow-ups, and wellbeing checks.
Monitor hospital admissions and discharges to ensure smooth transitions of care. Use health coaching and motivational interviewing techniques to support patients in managing their wellbeing. Maintain accurate records and contribute to data collection for service evaluation. Signpost to community and voluntary services, social prescribing, and wellbeing support.
About Us Newcastle Central PCN is a collaborative group of GP practices serving a diverse population in the heart of the city. We are committed to tackling health inequalities and delivering proactive, preventative care. This pilot is part of the NHS Ageing Well agenda and will shape the future of frailty care in the city. You will join a friendly, supportive and forward-thinking team including GPs, nurses, paramedics, pharmacists, social prescribers, and care coordinators.
Training and development will be provided, and you'll be supported to build your skills in personalised care and coordination.
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