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Shrewsbury Primary Care Network

PCN Frailty Care Coordinator

The closing date is 27 July 2025

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Job summary

The Frailty Care Coordinator will support patients identified as living with or at risk of frailty, helping them to live longer and avoid crisis events. This role aims to improve patient outcomes through proactive, personalised care planning and coordination, while also supporting carers and families. The coordinator will help reduce avoidable hospital admissions and support practices in managing complex frailty cases.

Main duties of the job

  • Identify patients at risk of frailty within the PCN using risk stratification tools.
  • Proactively contact and review patients identified as frail through the frailty team.
  • Develop and deliver personalised care plans tailored to each patient's needs and circumstances.
  • Support practices with complex frailty cases through Multi-Disciplinary Team (MDT) meetings.
  • Signpost and refer patients to appropriate community, voluntary, and social care services.
  • Book and coordinate regular review appointments as appropriate.
  • Monitor hospital discharges for patients with frailty and provide necessary follow-up support and interventions.
  • Provide advice and ongoing support to families and carers.

About us

Shrewsbury PCN is made up of 11 GP practices supporting over 104,000 patients in and around Shrewsbury, Shropshire.

We are passionate about leading a network that is supportive and collaborative, where members and staff feel appreciated and empowered to make a difference. Our ambition is to deliver exceptional care and have a positive impact on the community we serve.

Details

Date posted

10 July 2025

Pay scheme

Other

Salary

Depending on experience £12.80 - £13.31

Contract

Permanent

Working pattern

Full-time, Part-time, Flexible working

Reference number

A5355-25-0009

Job locations

Morgan Place

Anchorage Avenue, Shrewsbury Business Park

Shrewsbury

Shropshire

SY2 6FG


Job description

Job responsibilities

  • Build trusting and supportive relationships with patients and their families, acting as a named point of contact.
  • Liaise with GPs, nurses, allied health professionals, social care, and voluntary services to ensure coordinated care.
  • Educate and support patients and carers to understand frailty as a manageable condition.
  • Maintain accurate and up-to-date patient records and care plans.
  • Support practices in recognising and managing frailty, helping reduce demand on acute appointments and GP time.
  • Contribute to achieving the risk stratification element of the Capacity and Access Improvement Plan (CAIP).
  • Support future planning and resource use across the PCN to improve outcomes and efficiency.

Job description

Job responsibilities

  • Build trusting and supportive relationships with patients and their families, acting as a named point of contact.
  • Liaise with GPs, nurses, allied health professionals, social care, and voluntary services to ensure coordinated care.
  • Educate and support patients and carers to understand frailty as a manageable condition.
  • Maintain accurate and up-to-date patient records and care plans.
  • Support practices in recognising and managing frailty, helping reduce demand on acute appointments and GP time.
  • Contribute to achieving the risk stratification element of the Capacity and Access Improvement Plan (CAIP).
  • Support future planning and resource use across the PCN to improve outcomes and efficiency.

Person Specification

Experience

Essential

  • Experience of working in a role that requires a high degree of autonomy
  • Experience of working across a variety of multidisciplinary teams

Desirable

  • Experience in care coordination, health or social care, or similar patient-facing roles
  • Experience in working in primary care or community settings

Knowledge and Skills

Essential

  • Strong organisational skills, including planning, prioritising, time management and record keeping
  • Ability to work collaboratively, liaising with other stakeholders as needed for the collective benefit of patients
  • Ability to recognise and work within limits of competence and seek advice when needed
  • Ability to prioritise own workload
  • Computer efficient
  • Excellent written and verbal communication skills
  • Excellent team working skills
  • Able to work independently, showing initiative

Desirable

  • Knowledge of frailty and its impact on patients and carers
  • Knowledge of primary care and how it operates
  • Able to use clinical information systems
  • Training in personalised care planning or motivational interviewing

Qualifications

Essential

  • Educated to GCSE level or equivalent

Personal Attributes

Essential

  • Ability to demonstrate personal accountability, resilience and work well under pressure
  • Flexible and adaptable to team and service needs
  • Reliable, punctual and confident

Other

Essential

  • Meet DBS reference standards and criminal records checks
  • Access to own transport / full clean driving license
  • Ability to travel across the locality as and when needed
Person Specification

Experience

Essential

  • Experience of working in a role that requires a high degree of autonomy
  • Experience of working across a variety of multidisciplinary teams

Desirable

  • Experience in care coordination, health or social care, or similar patient-facing roles
  • Experience in working in primary care or community settings

Knowledge and Skills

Essential

  • Strong organisational skills, including planning, prioritising, time management and record keeping
  • Ability to work collaboratively, liaising with other stakeholders as needed for the collective benefit of patients
  • Ability to recognise and work within limits of competence and seek advice when needed
  • Ability to prioritise own workload
  • Computer efficient
  • Excellent written and verbal communication skills
  • Excellent team working skills
  • Able to work independently, showing initiative

Desirable

  • Knowledge of frailty and its impact on patients and carers
  • Knowledge of primary care and how it operates
  • Able to use clinical information systems
  • Training in personalised care planning or motivational interviewing

Qualifications

Essential

  • Educated to GCSE level or equivalent

Personal Attributes

Essential

  • Ability to demonstrate personal accountability, resilience and work well under pressure
  • Flexible and adaptable to team and service needs
  • Reliable, punctual and confident

Other

Essential

  • Meet DBS reference standards and criminal records checks
  • Access to own transport / full clean driving license
  • Ability to travel across the locality as and when needed

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.

Employer details

Employer name

Shrewsbury Primary Care Network

Address

Morgan Place

Anchorage Avenue, Shrewsbury Business Park

Shrewsbury

Shropshire

SY2 6FG


Employer's website

http://www.shrewsburypcn.co.uk/ (Opens in a new tab)

Employer details

Employer name

Shrewsbury Primary Care Network

Address

Morgan Place

Anchorage Avenue, Shrewsbury Business Park

Shrewsbury

Shropshire

SY2 6FG


Employer's website

http://www.shrewsburypcn.co.uk/ (Opens in a new tab)

Employer contact details

For questions about the job, contact:

People & Operations Manager

Yasmin Dunn

yasmin.dunn1@nhs.net

Details

Date posted

10 July 2025

Pay scheme

Other

Salary

Depending on experience £12.80 - £13.31

Contract

Permanent

Working pattern

Full-time, Part-time, Flexible working

Reference number

A5355-25-0009

Job locations

Morgan Place

Anchorage Avenue, Shrewsbury Business Park

Shrewsbury

Shropshire

SY2 6FG


Supporting documents

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