ORGANISATION SUMMARY:

The PCN comprises of 4 Practices across the Forest of Dean. Forest Green PCN consists of Dockham Surgery, Drybrook Surgery, Forest Health Care and Mitcheldean Surgery. The practices have a combined geographic area made up of around 29,000 patients. Our PCN is committed to developing a skilled multidisciplinary workforce that can maximise the delivery of safe, high quality and value for money healthcare services for the benefit of our local population. You will be joining an enthusiastic team of clinicians and administrators. You will be well supported with ongoing professional development (training support, CPD, and peer support). The role will contribute to improving the quality of care of our patients across the network of practices.
Forest Green PCN is a friendly and diverse team who are determined to make work-life balance achievable and enjoyable and are ready to welcome new employees into the network.

JOB SUMMARY

The Frailty Care Coordinator plays a vital role within the Primary Care Network (PCN), working proactively with people who are elderly, frail, or living with long-term conditions. The role involves coordinating and navigating care across health and social care services, enabling patients and their carers to better understand, manage, and improve their health outcomes.
This person-centred role ensures that patients receive holistic, joined-up care tailored to their individual needs through the development and implementation of personalised care and support plans. The Frailty Care Coordinator will work closely with Frailty Nurse, GPs, practice staff, social prescribing link workers, health and wellbeing coaches, and the wider multidisciplinary team to embed personalised care within the PCN.

· Act as a key contact for patients with frailty or long-term conditions, supporting them and their carers to understand and manage their health.
· Proactively identify and manage a caseload of patients, working collaboratively with PCN clinicians to prioritise those with the highest needs.
· Support patients to create, review, and manage personalised care and support plans, ensuring their goals and preferences are captured and respected. This includes supporting the Frailty Nurse in delivering the holistic element of Comprehensive Geriatric Assessments (CGAs) within patients’ homes, contributing to a coordinated, person-centred approach.
· Coordinate and navigate health and care services to ensure patients receive the right care, at the right time, from the right professionals.
· Help patients access appropriate support services such as self-management programmes, peer support, health coaching, and personal health budgets.
· Prepare patients for clinical conversations, enabling informed decision-making and promoting self-care.
· Accurately maintain and update patient records, ensuring timely input of data in line with clinical coding standards.
· Use clinical systems (SystmOne) to input and retrieve information, manage caseloads, generate reports, and log interventions.
· Manage patient contact records, referrals, appointments, and follow-ups with attention to detail and data protection policies.
· Track and record outcomes and interventions to support service evaluation and impact reporting.
· Coordinate multidisciplinary team (MDT) meetings by organising logistics, preparing agendas, and documenting minutes or action plans.
· Support the use of digital tools such as the Personalised Proactive Whiteboard (PPW) to identify patients for care coordination.
· Maintain filing systems (physical and digital) in line with information governance requirements.
· Liaise with practices and partner organisations to maintain effective communication and follow-up.
· Assist in audit, evaluation, and service improvement tasks as required by the PCN management team.
· Work with GPs and other primary care professionals to deliver integrated care.
· Promote collaborative working across health, social care, and voluntary sectors.
· Identify and support carers, helping them access relevant services.
· Actively contribute to the development of communication channels between the PCN, patients, and community resources.
· Completion of Personalised Care Institute (PCI) accredited Care Coordination Training (or willingness to complete upon appointment).
· Personalised Proactive Whiteboard (PPW) training, including: SY1 Clinical System: coding, caseload management, patient record keeping. Microsoft Excel: data entry, sorting, filtering, and basic formatting.
Job Types: Part-time, Fixed term contract
Contract length: 12 months
Pay: £15.86-£17.87 per hour
Expected hours: 22.5 – 35 per week

Benefits:

• On-site parking
• Sick pay

Work Location: In perso