Frailty Care Coordinator/Health & Wellbeing Practitioner in Hyde

DAD PCN have an exciting opportunity for a Frailty Care Coordinator/Health & Wellbeing Practitioner to join our Primary Care Network. The role will primarily involve assisting our 6 GP practices across the locality with a caseload of housebound frail patients. This post will also work with community services and practices to promote the National cancer screening uptake in Denton and Droylsden.

The role involves working very closely with the practices and the multidisciplinary team (MDT) within the PCN. It is pivotal in ensuring all residents receive the best possible care and service. The role will support the PCN team in coordinating all key activity including access to services, advice, and information, and ensuring health and care planning is timely, efficient, and patient-centred. The role involves working in the community providing proactive clinics to targeted patients in conjunction with the PCN/practice teams.

• The postholder will engage in positive, empathetic conversations with residents, families, and carers to identify needs and support the development, implementation, and regular review of personalised care plans.
• Care plans will be communicated to GPs and relevant professionals and uploaded to appropriate care records using SNOMED coding.
• Working within a PCN, the postholder will proactively support people, including the frail, elderly, and those with long-term conditions, coordinating care across health and social services.
• They will manage a patient caseload in close collaboration with GP teams, acting as a central point of contact for patients and carers.
• The role involves regular liaison with multidisciplinary teams, participation in MDT meetings, escalation of concerns to named clinical contacts, and identification of safety issues or additional support needs.
• The postholder will contribute to quality health outcomes and undertake clinical tasks as appropriate to training, including blood pressure monitoring, phlebotomy, and chaperoning.
• They will follow agreed clinical protocols, recognise and report changes in patients' conditions, maintain accurate patient records, and work effectively as part of a multidisciplinary team, liaising with colleagues and patients as required.

Denton Primary Care Network is a collaboration of the primary care teams based at 3 Denton general medical practices and 3 Droylsden based general medical practices. We currently have a PCN population of approximately 52,000 patients and the PCN staff work in conjunction with the local general practices to support both local and national priorities working closely with our local care homes, housebound and most vulnerable patients.

• The postholder will be able to participate in positive, empathetic and responsive conversations with residents and their family and carer(s) about their needs.
• Support people to develop and implement personalised care plans. Review and update personalised care and support plans at regular intervals.
• Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the person's care and uploaded to the relevant online care records, with activity recorded using the relevant SNOMED codes.
• The postholder will play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.
• They work closely with GP teams to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers.
• The role will involve regular liaison with the range of multidisciplinary professionals and colleagues involved in the residents' care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported.
• Actively participate in multidisciplinary team meetings in the PCN as and when appropriate, identifying when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.
• Carry out and co-ordinate quality health outcomes. This may include but not exclusively the following based on training and experience: Blood pressure monitoring, Phlebotomy, Act as a chaperone if required.
• Undertake activities identified by the clinical team in accordance with agreed written protocols.
• Understand when to report changes in a patient's condition.
• Make clear & accurate entries into a patient's records when appropriate.
• Work as an effective team member. Liaise with other team members and patients.

• Good standard of education standard grades at Grade A-C or equivalent, including maths and English.
• Recognised healthcare qualification or Health & Social Care Qualification at NVQ level 3 or Care Co-ordinator Person Centred Care Course.
• Experience in healthcare assistant role in a medical/healthcare setting or similar services.
• Experience of working with an EPR.
• Child & Adult Safeguarding Basic Life Support CPR/AED skills.
• Experience of working with the EMIS GP software system.
• Experience of working in primary care.
• Trained to administer vaccinations on adults.
• Understanding of nursing role and HCA supporting role within a healthcare environment.
• Experience of dealing effectively with the general public.
• Excellent communication skills both written and oral.
• Good management and prioritisation of workload.
• Ability to multi-task.
• Able to work well under pressure and to deadlines.
• Ability to work without direct supervision.
• Ability to work well in a team.
• Sensitivity and ability to empathise.
• Confidence, tact and diplomacy.
• Confidentiality.
• Initiative, flexibility and adaptability.
• Accurate and thorough approach.
• Observations and recording.
• Basic IT Skills.

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Depending on experience Pay Negotiable & dependant on experience: ARRS Band 4 / Band 5.