Job summary
Aspen Medical Practice Primary Care Network are seeking a Frailty Care Co-ordinator to join our well-established Frailty Team. This exciting new post will offer applicants the opportunity to improve the lives of our patients who are living with frailty and dementia.
We are looking for someone with a passion for working with frail and/or elderly patients and those living with dementia. An empathetic and sensitive communicator who understands their own limitations and works well within a team
Previous experience of working in a patient facing setting within health or social care is essential. We are seeking applicants with strong interpersonal skills, who is an excellent communicator and is able to work both alone and alongside a team.
A full UK driving license and access to a vehicle is essential for travel either between sites or to patient's homes.
This role will involve some administration and working alongside our newly formed dementia diagnosis MDT.
The role is available for participants who are seeking to work 25 to 37.5 hours
Interviews for this post will take place on 27/01/2026 and invites for interview will be sent 20/01/2026 to successful applicants.
Main duties of the job
The Frailty Care Coordinator is an essential member of Aspens Frailty Team, responsible for proactively identifying and supporting individuals living with moderate to severe frailty and/or dementia. The postholder will ensure that patients receive co-ordinated, person-centred care and are able to navigate health, social care, and community services effectively.
In this role, the postholder will act as a point contact for patients and their carers,
providing guidance, facilitating access to appropriate support, and helping
individuals understand and manage their conditions. The Frailty Care
Coordinator will also ensure that any changes in a patient's needs are
recognised, communicated, and responded to promptly.
The post holder will act as a main point of contact for patients, carers and health professionals either by telephone, email or face to face. They will work alongside GPs and other members of the practice team as well as a range of other health, social and community teams and partners to ensure seamless care and communication. The postholder will be giving advice and signposting to other services but also seeking advice from their team or other members of the practice when needed.
This role is vital in helping deliver high-quality, seamless care to
some of the most vulnerable members of the community.
About us
Aspen Medical Practice is a large, single-practice Primary Care Network
(PCN) serving just over 32,000 patients. We operate from one modern main
super-surgery, supported by two branch sites, and work together as one
cohesive, integrated team. This role will be primarily based at our main site.
Aspen Medical Practice has a higher-than-average proportion of older and
frail patients, and we have developed a strong, well established Frailty Team
to meet their needs. The team currently consists of two Frailty Matrons and two
Social Prescribers, all working collaboratively to deliver high-quality,
person-centred care.
By joining us, you will become part of a dedicated and experienced team
with a genuine passion for supporting the local frail population and enhancing
their health, wellbeing, and overall quality of life.
Job description
Job responsibilities
Key responsibilities include:
- Frailty case identification
- Managing own caseload
- Holistic assessment of patients with frailty or at risk of frailty
- Providing frail patients with personalised care and support plans
- Working with a wide range of other professionals, carers and patients to provide safe and effective care
- Responsibility for arranging and providing administration support for the dementia co-diagnosis model.
- Maintaining accurate, up-to-date records in line with practice and PCN requirements.
- Providing general administrative support to the Frailty Team as require.
Job description
Job responsibilities
Key responsibilities include:
- Frailty case identification
- Managing own caseload
- Holistic assessment of patients with frailty or at risk of frailty
- Providing frail patients with personalised care and support plans
- Working with a wide range of other professionals, carers and patients to provide safe and effective care
- Responsibility for arranging and providing administration support for the dementia co-diagnosis model.
- Maintaining accurate, up-to-date records in line with practice and PCN requirements.
- Providing general administrative support to the Frailty Team as require.
Person Specification
Qualifications
Essential
- Good standard of education with minimum 5 GCSE's or equivalent.
- Good IT skills - ability to use MS Office (Word, Excel, Outlook, Powerpoint) to a good standard.
- Full UK Driving License
Desirable
- Care Planning and Coordination qualification
- Educated to a higher level
- Qualification in health coaching/ motivational interviewing or equivalent
Experience
Essential
- Experience of working in a primary care setting
- Experience in organising meetings, preparing agendas and writing minutes.
- Excellent communication skills and effective in communicating and understanding patient needs
- Effective time management (planning and organising)
- Competent in the use of MS Office and Outlook
- Effective time management (planning and organising)
- Ability to use own initiative, discretion, and sensitivity
- Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity
- Sensitive and empathetic in distressing situations
- Good organisational skills
- Ability to effectively utilise resources
- Punctual and committed to supporting the team effort
- High levels of integrity and loyalty
- Commitment to ongoing professional development
- Motivated
- Problem solver with the ability to process information accurately and effectively, interpreting data as required
- Ability to work under pressure/in stressful situations
- Demonstrate personal accountability, emotional resilience and ability to work well under pressure
- Knowledge of and ability to work to key policies and procedures
Desirable
- Experience of working in general practice
- Experience of frailty or care co-ordination
- Experience managing administrative workflows in a healthcare setting.
- Experience of using data tools to report on outcomes or service delivery.
Person Specification
Qualifications
Essential
- Good standard of education with minimum 5 GCSE's or equivalent.
- Good IT skills - ability to use MS Office (Word, Excel, Outlook, Powerpoint) to a good standard.
- Full UK Driving License
Desirable
- Care Planning and Coordination qualification
- Educated to a higher level
- Qualification in health coaching/ motivational interviewing or equivalent
Experience
Essential
- Experience of working in a primary care setting
- Experience in organising meetings, preparing agendas and writing minutes.
- Excellent communication skills and effective in communicating and understanding patient needs
- Effective time management (planning and organising)
- Competent in the use of MS Office and Outlook
- Effective time management (planning and organising)
- Ability to use own initiative, discretion, and sensitivity
- Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity
- Sensitive and empathetic in distressing situations
- Good organisational skills
- Ability to effectively utilise resources
- Punctual and committed to supporting the team effort
- High levels of integrity and loyalty
- Commitment to ongoing professional development
- Motivated
- Problem solver with the ability to process information accurately and effectively, interpreting data as required
- Ability to work under pressure/in stressful situations
- Demonstrate personal accountability, emotional resilience and ability to work well under pressure
- Knowledge of and ability to work to key policies and procedures
Desirable
- Experience of working in general practice
- Experience of frailty or care co-ordination
- Experience managing administrative workflows in a healthcare setting.
- Experience of using data tools to report on outcomes or service delivery.
Disclosure and Barring Service Check
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.
