Primary Care Network Frailty Care Co-ordinator

**Job Description Job Title**: Primary Care Network Frailty Care Co-ordinator Accountable to: Partners & Visiting Team Lead Location: Designated GP Practices Job Summary - A frailty care coordinator holistically supports patients with mild to severe frailty within the community. They work with patients to create a patient-centred care plan and provide access to support services within the area that are most appropriate for them. Working as part of a multi-disciplinary team you will support the delivery of patient care across the PCN aligned Care Homes and housebound patients. The post holder will provide appropriate care and support and will focus on individual patient needs and will ensure any changing needs are addressed.

Signposting individuals in order that they may access appropriate support from other services as appropriate. Identification of patients living with frailty and pro-actively working with those patients to intervene before crisis. Ensure the PCN meets the DES specifications for frailty and Enhanced Health in Care Homes Administrative duties focus on providing coordination, a point of contact for both the home and clinical staff and ensuring there are robust process and pathways between Primary, Secondary and Community Care. Job Responsibilities To collaborate with Practices and the broader community care team to ensure that patients living with frailty receive appropriate interventions aimed at assisting them in maintaining as much independence as possible.

To visit and support patients at their place of residence to assess any unmet health or care needs. To complete holistic person centred care planning. Where unmet are identified to completed relevant referrals into appropriate organisations. To attend the weekly ICC MDT meetings where appropriate.

OT, ICT, CPN, nursing home staff etc.), Community and hospital pharmacy teams, Community Health and Social Care Teams, ICC Teams, Care Organisations, Patients and carers, Community pharmacists, Practice Pharmacists, Other primary care health professionals, Third Sector Organisations Duties and Responsibilities of the Post - The purpose of the role will be to support patients living with frailty, reviewing their care plans and ensuring they are supported to live well in their place of residence. To support the PCN practices to meet the requirements of the Enhanced Care in Care Homes, Personalised and Anticipatory Care model, this will include primary care support and some community based support. Proactively targeting patients identified as living with frailty. In partnership with their carers/relatives, carry out an holistic assessment which encompasses health and social care aspects of care.

Conduct low level clinical screening such as dementia screening, blood pressure checks and venepuncture as directed by the lead health professional. (Where relevant training has been received) Falls risk assessments to be undertaken. Provide a care plan and refer as appropriate to other organisations or provide support as required to ensure patient is well supported. Act on communications from hospitals or community providers, ensuring care plans are updated in a timely manner.

Act on incoming requests from patients, carers, care homes and other providers Have the ability to organise and prioritise own workload. Proactively support patients to take up vaccinations such as flu and covid and participate in the delivery of these. Work collaboratively with other care coordinators across the PCN to share best practice To participate in discussions about the direction of service developments and improvements. To participate in service audits and changes.

To participate in appraisal processes and participate in CPD/ personal development plan. To pro-actively participate in mandatory training and in-service training