A new Frailty Team post with Coastal Primary Care Network, based at St Agnes and Perranporth surgeries, on an 18-month fixed term. The role coordinates personalised care for patients with frailty, long-term conditions or complex needs, linking GP practices with community, social care and voluntary services. Hours are part-time or full-time, with work across several sites and home visits. A driving licence and access to a vehicle are required for the travel involved.
What the job involves
- Coordinate personalised care plans and act as a central contact for patients and their families where appropriate
- Identify and manage caseloads of patients with frailty, multiple long-term conditions, complex social needs or involvement from several agencies
- Coordinate care across primary, secondary, community, social care and voluntary services, and support smooth transitions between them
- Support patients after hospital discharge, act on discharge summaries and identify those at risk of avoidable admission
- Take part in multidisciplinary team meetings and coordinate the actions arising from them
- Help patients access community, social prescribing and voluntary sector services, working alongside Social Prescribing Link Workers
- Support long-term condition reviews, follow-up and annual reviews
- Provide assessments in patients' homes
- Carry out basic physical health checks such as weight, blood pressure and blood tests, after training
- Maintain accurate clinical records and produce reports on activity and performance
- Recognise and respond to safeguarding concerns and escalated clinical and non-clinical risks promptly
- Contribute to service development, audit and evaluation, and support new pathways
Qualifications
- Educated to GCSE level or equivalent, including English and Mathematics
- Evidence of continuing professional development
Experience
- Working in health, social care, community or voluntary sector services
- Supporting vulnerable individuals
- Managing competing priorities and workloads
- Communicating with a range of stakeholders and professionals, and maintaining accurate records
Skills & knowledge
- Understanding of person-centred care and multidisciplinary working
- Knowledge of confidentiality, data protection and safeguarding responsibilities
- Awareness of health inequalities and the wider determinants of health
- Excellent communication skills and the ability to build relationships with patients and professionals
- Strong organisation, time management, and the ability to work independently and in a team
- Good problem-solving, strong IT skills including Microsoft Office, and handling sensitive or distressing situations
Checks & eligibility
- Full UK driving licence and access to a vehicle
Other
- Commitment to high-quality, patient-centred care
- Flexible approach to working across multiple sites
- Ability to travel between PCN locations and carry out home visits
Nice to have
- Experience in general practice or primary care
- Care coordination or case management experience
- Experience in multidisciplinary teams, with facilitation and meeting coordination skills
- Experience supporting frail patients or those with long-term conditions
- Care Coordinator qualification or Personalised Care Institute training
- Level 3 or above in health, social care or business administration, or equivalent experience
- Mental Health First Aid training or a health coaching qualification
- Knowledge of NHS systems and SystmOne, and experience with population health and reporting systems
What’s offered
- Training provided for basic physical health checks
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Contact Details:
The Methodist Church in Britain Recruitment Team
