PCN Care Coordinator - FrailtyNHS

Job summary

We are seeking a compassionate and proactive Care Coordinator to join our Frailty Team within Worcester City PCN. In this rewarding role, you will work closely with patients living with frailty, long-term conditions, and complex health needs, helping them navigate health and social care services and ensuring they receive coordinated, person-centred support. As a key member of the multidisciplinary team, you will build strong relationships with patients, carers, healthcare professionals, and partner organisations, enabling individuals to access the right care at the right time and improve their overall wellbeing and quality of life.

This role is 37.5 hours per week - 8:30am to 4:00pm per day and Saturdays when required.

Location: St Martin's Gate Surgery with visits to other PCN practices and home visits (where appropriate).

Main duties of the job

The Care Coordinator - Frailty will support individuals living with frailty and complex health needs by coordinating care across a range of health, social care, and voluntary services. The post holder will act as a key point of contact for patients and their carers, carrying out personalised care planning, supporting access to appropriate services, and helping individuals manage their health and wellbeing. Working closely with GPs, community teams, and other healthcare professionals, the Care Coordinator will ensure patients receive timely, joined-up care, reduce barriers to accessing support, and contribute to improving health outcomes and maintaining independence wherever possible.

Job description

The Care Coordinator - Frailty plays a vital role in supporting patients living with frailty, long-term conditions, and complex health and social care needs. Working as part of a multidisciplinary team, the post holder will coordinate care, provide personalised support, and help patients access appropriate services to improve their health, wellbeing, and independence. The role focuses on delivering person-centred care, reducing health inequalities, and ensuring patients receive the right support at the right time.

Key Responsibilities:

• Act as a key point of contact for patients identified as living with frailty and their carers.
• Support the identification and management of patients who would benefit from coordinated care and personalised support.
• Develop, implement, and review personalised care and support plans in collaboration with patients, carers, and healthcare professionals.
• Coordinate care across primary care, community services, social care, and voluntary sector organisations.
• Signpost and refer patients to appropriate health, wellbeing, and community-based services.
• Support patients to access appointments, investigations, treatments, and other relevant services.
• Maintain regular contact with patients to monitor progress and identify any changes in need.
• Work collaboratively with GPs, nurses, pharmacists, social prescribers, community teams, and other healthcare professionals.
• Assist in reducing unnecessary hospital admissions and supporting safe discharge planning where appropriate.
• Promote self-management, independence, and preventative healthcare initiatives.
• Maintain accurate, timely, and confidential patient records in line with organisational policies and information governance requirements.
• Participate in multidisciplinary team meetings and contribute to case discussions.
• Support quality improvement initiatives and service development activities relating to frailty care.

About us

We are a federation of GP surgeries and PCNs in Worcestershire, serving over 600,000 NHS patients through a variety of local services. Our community of GPs are our stakeholders, meaning were powered by the community we've created - and our goal is to find ways to make it easier for them to spend less time and money on administrative workload, and more time with their patients.

Our GP surgeries remain independent, while keeping the benefits of being part of a larger organisation - and we exist to protect the interests of our members through advocacy, business support, and revenue generation.

We are ambitious about growth in our network - and so, our diversified services help our PCNs to reinvest in vital local healthcare initiatives, providing a sustainable future for their communities in the long term.