Job summary
Newcastle Central PCN is excited to launch a Frailty Pilot
Service to provide proactive, person-centred support for older adults living
with frailty. We are looking for an enthusiastic and compassionate Care
Coordinator to join our new multidisciplinary frailty team.
As Care Coordinator, you will work closely with Advanced Nurse
Practitioners, GPs, social prescribers, and community teams to ensure patients
with frailty receive timely, coordinated, and holistic care. You will act as a
central point of contact for patients, families, and servicessupporting care
planning, follow-up, and continuity across different settings, document data
from assessments to facilitate identification of outcomes and ensure relevant
documentation is available for the ANP and health coaches.
This is an ideal opportunity for someone with a
background in health, social care, or support work who is passionate about
helping older people to live well in their communities.
Main duties of the job
Proactively identify and engage patients living with frailty,
using frailty tools and risk stratification.
Support the coordination of care for patients, including
arranging appointments, home visits, and referrals to appropriate services,
check in with patients to review their progress with their action plans between
formal reviews.
Act as a named contact for patients and carers, ensuring they
understand their care plans and know who to contact.
Liaise with internal and external services including GPs,
community nursing, adult social care, mental health, and voluntary sector
organisations.
Help coordinate Multi-Disciplinary Team (MDT) meetings and
follow up actions.
Support personalised care planning and advanced care planning
conversations, ensuring patient voice and choice are central.
Assist with tracking and recalling patients for reviews,
follow-ups, and wellbeing checks.
Monitor hospital admissions and discharges to ensure smooth
transitions of care.
Use health coaching and motivational interviewing techniques
to support patients in managing their wellbeing.
Maintain accurate records and contribute to data collection
for service evaluation.
Signpost to community and voluntary services, social
prescribing, and wellbeing support.
About us
Newcastle Central PCN serves a diverse urban population and is
committed to delivering high-quality, patient-centred care. This new frailty
service is part of our commitment to integrated, preventative, and
person-focused healthcare.
Our PCN is made up of experienced and supportive
teams, including GPs, pharmacists, paramedics, care coordinators, social
prescribers, and mental health practitioners. You will be supported by strong
clinical leadership and a responsive management team that values innovation and
flexibility.
Job description
Job responsibilities
Newcastle Central PCN is excited to launch a Frailty Pilot
Service to provide proactive, person-centred support for older adults living
with frailty. We are looking for an enthusiastic and compassionate Care
Coordinator to join our new multidisciplinary frailty team.
As Care Coordinator, you will work closely with Advanced Nurse
Practitioners, GPs, social prescribers, and community teams to ensure patients
with frailty receive timely, coordinated, and holistic care. You will act as a
central point of contact for patients, families, and servicessupporting care
planning, follow-up, and continuity across different settings, document data
from assessments to facilitate identification of outcomes and ensure relevant
documentation is available for the ANP and health coaches.
This is an ideal opportunity for someone with a background in
health, social care, or support work who is passionate about helping older
people to live well in their communities.
Main Duties of the Job
Proactively identify and engage patients living with frailty,
using frailty tools and risk stratification.
Support
the coordination of care for patients, including arranging appointments,
home visits, and referrals to appropriate services, check in with patients to review their
progress with their action plans between formal reviews.
Act as a named contact for patients and carers, ensuring they
understand their care plans and know who to contact.
Liaise with internal and external services including GPs,
community nursing, adult social care, mental health, and voluntary sector
organisations.
Help coordinate Multi-Disciplinary Team (MDT) meetings and
follow up actions.
Support personalised care planning and advanced care planning
conversations, ensuring patient voice and choice are central.
Assist with tracking and recalling patients for reviews,
follow-ups, and wellbeing checks.
Monitor hospital admissions and discharges to ensure smooth
transitions of care.
Use health coaching and motivational interviewing techniques
to support patients in managing their wellbeing.
Maintain accurate records and contribute to data collection
for service evaluation.
Signpost to community and voluntary services, social
prescribing, and wellbeing support.
About Us
Newcastle Central PCN is a collaborative group of GP practices
serving a diverse population in the heart of the city. We are committed to
tackling health inequalities and delivering proactive, preventative care. This
pilot is part of the NHS Ageing Well agenda and will shape the future of
frailty care in the city.
You will join a friendly, supportive and forward-thinking team
including GPs, nurses, paramedics, pharmacists, social prescribers, and care
coordinators. Training and development will be provided, and you'll be
supported to build your skills in personalised care and coordination.
Job description
Job responsibilities
Newcastle Central PCN is excited to launch a Frailty Pilot
Service to provide proactive, person-centred support for older adults living
with frailty. We are looking for an enthusiastic and compassionate Care
Coordinator to join our new multidisciplinary frailty team.
As Care Coordinator, you will work closely with Advanced Nurse
Practitioners, GPs, social prescribers, and community teams to ensure patients
with frailty receive timely, coordinated, and holistic care. You will act as a
central point of contact for patients, families, and servicessupporting care
planning, follow-up, and continuity across different settings, document data
from assessments to facilitate identification of outcomes and ensure relevant
documentation is available for the ANP and health coaches.
This is an ideal opportunity for someone with a background in
health, social care, or support work who is passionate about helping older
people to live well in their communities.
Main Duties of the Job
Proactively identify and engage patients living with frailty,
using frailty tools and risk stratification.
Support
the coordination of care for patients, including arranging appointments,
home visits, and referrals to appropriate services, check in with patients to review their
progress with their action plans between formal reviews.
Act as a named contact for patients and carers, ensuring they
understand their care plans and know who to contact.
Liaise with internal and external services including GPs,
community nursing, adult social care, mental health, and voluntary sector
organisations.
Help coordinate Multi-Disciplinary Team (MDT) meetings and
follow up actions.
Support personalised care planning and advanced care planning
conversations, ensuring patient voice and choice are central.
Assist with tracking and recalling patients for reviews,
follow-ups, and wellbeing checks.
Monitor hospital admissions and discharges to ensure smooth
transitions of care.
Use health coaching and motivational interviewing techniques
to support patients in managing their wellbeing.
Maintain accurate records and contribute to data collection
for service evaluation.
Signpost to community and voluntary services, social
prescribing, and wellbeing support.
About Us
Newcastle Central PCN is a collaborative group of GP practices
serving a diverse population in the heart of the city. We are committed to
tackling health inequalities and delivering proactive, preventative care. This
pilot is part of the NHS Ageing Well agenda and will shape the future of
frailty care in the city.
You will join a friendly, supportive and forward-thinking team
including GPs, nurses, paramedics, pharmacists, social prescribers, and care
coordinators. Training and development will be provided, and you'll be
supported to build your skills in personalised care and coordination.
Person Specification
Experience
Essential
- Experience in a health, social care, voluntary or public sector setting
- Supporting individuals with long-term conditions, frailty or complex needs
- Working with vulnerable or older adults
- Collaborative working with other services/agencies
- Using digital systems for record keeping and communication
Desirable
- Experience working in primary care or a PCN
- Experience coordinating care or managing referrals
- Working with patients with cognitive impairment or dementia
Qualifications
Essential
- Good general education (GCSEs or equivalent)
- NVQ Level 3 in health/social care or equivalent experience
- Evidence of ongoing learning and development
Desirable
- Care Coordination or Health Coaching training
- Personalised Care Institute (PCI) accredited training
- IT or administration qualification
Knowledge & Skills
Essential
- Understanding of frailty and its impact on individuals and families
- Excellent interpersonal and communication skills
- Organised, proactive and able to prioritise tasks
- Empathy, patience and active listening
- IT skills (Microsoft Office, clinical systems like EMIS or SystmOne)
- Ability to work independently and as part of a team
- Commitment to confidentiality and safeguarding principles
Other
Essential
- Willingness to travel across practices and to patients homes if needed
- Flexible and responsive to service needs
- Passion for personalised care and improving patient outcomes
- Willingness to undertake relevant training and development
Person Specification
Experience
Essential
- Experience in a health, social care, voluntary or public sector setting
- Supporting individuals with long-term conditions, frailty or complex needs
- Working with vulnerable or older adults
- Collaborative working with other services/agencies
- Using digital systems for record keeping and communication
Desirable
- Experience working in primary care or a PCN
- Experience coordinating care or managing referrals
- Working with patients with cognitive impairment or dementia
Qualifications
Essential
- Good general education (GCSEs or equivalent)
- NVQ Level 3 in health/social care or equivalent experience
- Evidence of ongoing learning and development
Desirable
- Care Coordination or Health Coaching training
- Personalised Care Institute (PCI) accredited training
- IT or administration qualification
Knowledge & Skills
Essential
- Understanding of frailty and its impact on individuals and families
- Excellent interpersonal and communication skills
- Organised, proactive and able to prioritise tasks
- Empathy, patience and active listening
- IT skills (Microsoft Office, clinical systems like EMIS or SystmOne)
- Ability to work independently and as part of a team
- Commitment to confidentiality and safeguarding principles
Other
Essential
- Willingness to travel across practices and to patients homes if needed
- Flexible and responsive to service needs
- Passion for personalised care and improving patient outcomes
- Willingness to undertake relevant training and development
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.
