PCN Frailty and Data Analyst / Care Home Care CoordinatorNHS

Job summary

The PCN Frailty and Data Analyst / Care Home Care Coordinator will play a key role in supporting the PCN's proactive approach to frailty, population health management and the delivery of integrated, person-centred care.

The postholder will be responsible for identifying and analysing patient populations, supporting risk stratification, monitoring service performance and providing accurate, meaningful data to inform clinical decision-making, service improvement and strategic planning.

Working closely with the PCN Frailty ACP, GP practices and multidisciplinary teams, the postholder will support the identification of patients living with moderate to severe frailty, helping to ensure that appropriate interventions, assessments and care planning are prioritised.

The role will also include one dedicated day per week working as a Care Coordinator within the PCN Care Home Team, supporting the coordination of care for residents, improving communication between services and ensuring patients receive timely, joined-up support.

The postholder will contribute to the PCN's wider neighbourhood health and population health management objectives, including reducing avoidable hospital admissions, improving proactive care and supporting patients to remain well and independent for as long as possible.

Please see the JD and person specification for full details.

Main duties of the job

Key responsibilities:

• Frailty identification and population health management
• Data Analysis, reporting and performance monitoring
• Frailty service development and quality improvement
• Care home care coordination - one day per week
• Communication and collaborative working
• Information governance and confidentiality
• General responsibilities

Please see JD and person specification for more information.

Job description

2. Key Responsibilities

Frailty Identification and Population Health Management

• Support the identification and monitoring of patients living with moderate to severe frailty across the PCN.
• Develop, run and maintain clinical searches using EMIS Web and other approved clinical and population health management systems.
• Support the identification of priority frailty cohorts, including patients aged 65 and over, those with Rockwood Clinical Frailty Scores of 69 and housebound patients.
• Work alongside the Frailty ACP, GP practices, and other stakeholders to identify patients who may benefit from proactive assessment, intervention or multidisciplinary review.
• Support the development and maintenance of frailty registers, ensuring data is accurate, current and appropriately coded.
• Identify patients requiring Comprehensive Geriatric Assessments (CGA), reviews or proactive interventions, referring these to the appropriate clinician or team for consideration.
• Undertake regular reviews of frailty population data to identify changes in risk, emerging needs and opportunities for earlier intervention.
• Support the identification of patients at increased risk of hospital admission, deterioration or poor health outcomes.
• Assist with identifying gaps in care and inequalities in access to frailty services.
• Work with clinical teams to support targeted interventions and proactive care planning.

Data Analysis, Reporting and Performance Monitoring

• Collect, analyse and interpret clinical and operational data to support the delivery of PCN priorities.
• Develop and maintain spreadsheets, dashboards and reports to monitor frailty activity, outcomes and service performance.
• Produce regular reports for the PCN Operations Manager, Clinical Director, Frailty ACP and PCN Board.
• Monitor key performance indicators, including:
• Identification and prevalence of moderate to severe frailty.
• Completion of Comprehensive Geriatric Assessments.
• Proactive care reviews and personalised care plans.
• Emergency department attendances and non-elective hospital admissions.
• Hospital bed days and readmissions, where data is available.
• Care home activity and multidisciplinary reviews.
• Identification of patients approaching end of life and appropriate care planning.
• Health inequalities and variation between practices.
• Support the collection and analysis of data required for PCN contractual requirements, locally commissioned services and neighbourhood health programmes.
• Identify trends, variations and opportunities for quality improvement.
• Present complex data in a clear and accessible format for clinical and non-clinical colleagues.
• Support data validation, coding quality and the accuracy of patient registers.
• Assist with audits, service evaluations and quality improvement projects.
• Work with relevant colleagues to ensure reporting deadlines are achieved.

Frailty Service Development and Quality Improvement

• Work collaboratively with the Frailty ACP and wider PCN team to support the development of proactive frailty pathways.
• Assist in evaluating the effectiveness of frailty interventions and identifying opportunities to improve patient outcomes.
• Support the implementation and monitoring of quality improvement initiatives.
• Contribute to service development projects aimed at reducing avoidable hospital admissions and supporting care closer to home.
• Support the development of standardised processes for frailty identification, referral, coding and monitoring across member practices.
• Participate in multidisciplinary discussions and service improvement meetings where appropriate.
• Assist with the preparation of reports and presentations demonstrating the impact and outcomes of frailty services.
• Support the PCN's neighbourhood health priorities, including prevention, integrated working and addressing health inequalities.
• Contribute to population health management projects, using data to identify patients who may benefit from additional support.

Care Home Care Coordination One Day Per Week

The postholder will dedicate one working day per week to supporting the PCN Care Home Team, working collaboratively with the Health & Care Trust (HACT), GPs, care home staff and wider multidisciplinary professionals.

Responsibilities will include:

• Act as a point of contact between the PCN Care Home Team, care home staff, GP practices and relevant community services.
• Support the coordination of care for residents within the PCN's aligned care homes.
• Assist with arranging and preparing for care home multidisciplinary team (MDT) meetings and clinical reviews.
• Identify residents requiring routine reviews, follow-up appointments or additional support, escalating clinical concerns to the appropriate clinician.
• Coordinate referrals and follow-up actions arising from MDT discussions and clinical reviews.
• Support the administrative coordination of personalised care and support plans, ensuring relevant information is recorded and shared appropriately.
• Liaise with community nursing teams, social care, pharmacy teams, social prescribing services and other professionals to facilitate joined-up care.
• Support communication and information sharing following hospital admissions and discharges.
• Maintain accurate records of care coordination activity and ensure agreed actions are followed up.
• Assist with monitoring care home service activity and outcomes.
• Support residents and their families or representatives to access appropriate services, within the boundaries of the role.
• Identify and escalate concerns relating to safeguarding, patient safety or deterioration in a resident's condition through established procedures.
• Support the effective organisation and administration of care home visits and reviews.

The Care Coordinator element of the role is non-clinical and does not involve undertaking clinical assessments, making diagnoses or providing clinical advice.

Communication and Collaborative Working

• Develop effective working relationships with PCN member practices, clinical teams and wider neighbourhood partners.
• Work closely with the Frailty ACP to ensure data analysis supports clinical priorities and service delivery.
• Communicate findings and recommendations clearly to colleagues with varying levels of data knowledge.
• Support multidisciplinary working across primary care, community services, care homes, local authority and voluntary sector organisations.
• Attend relevant meetings and contribute to discussions on frailty, population health management and service improvement.
• Maintain professional and confidential communication with patients, carers and healthcare professionals.
• Escalate operational concerns, data quality issues and potential risks appropriately.

Information Governance and Confidentiality

• Ensure compliance with UK GDPR, the Data Protection Act 2018, NHS information governance requirements and organisational policies.
• Maintain the confidentiality and security of patient-identifiable and organisational information.
• Access patient records only where authorised and necessary for the role.
• Ensure data is collected, processed, stored and shared securely and appropriately.
• Follow relevant policies relating to clinical systems, information sharing and cyber security.
• Maintain accurate and contemporaneous records.
• Complete mandatory information governance and data protection training.

3. General Responsibilities

The postholder will be expected to:

• Work within the policies and procedures of the employing organisation and PCN.
• Maintain professional boundaries and recognise the limitations of the role.
• Complete mandatory and statutory training.
• Participate in regular supervision, one-to-one meetings and performance reviews.
• Take responsibility for continuing professional development.
• Promote equality, diversity, inclusion and person-centred care.
• Follow safeguarding policies and report concerns promptly.
• Support a positive, collaborative and improvement-focused working environment.
• Undertake other reasonable duties consistent with the responsibilities and level of the post

Please see attached JD and person specification for more details.

About us

About Droitwich Ombersley & the Rurals Primary Care Network

Droitwich, Ombersley & The Rurals PCN consists of 7 practices, based across South Worcestershire, serving 57,000 patients. We aim to offer and deliver excellent, safe, co-ordinated, high-quality patient care. Continuously learning, evolving, and implementing new models of care, to create inclusion, reduce health inequalities and health improve outcomes.

We work hard to promote a culture where staff feel engaged, valued, and recognised by the organisation and the others they work with.

We have an Additional Roles team of 35 healthcare professionals and are looking for an individual with a passion to deliver excellent service in General Practice and in the local communities.