Job description

Job responsibilities

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.

• 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.

Person Specification

Knowledge

Essential

• Knowledge and understanding of the health and social care sector.
• Knowledge of safeguarding, confidentiality and GDPR and the best practice approaches.
• Equal Opportunities and Diversity.

Desirable

• Understanding and knowledge of the role, practice, and principles of care planning.
• Knowledge of EMIS database and application within an operational/administrative role.
• Social and health care systems and processes.
• A working knowledge of relevant legislation including Data Protection.

Experience

Essential

• Significant previous experience of working in a proactive administrative role.
• Working within a social care/health or related environment in a delivery or front face role.
• Working with people who are vulnerable or face disadvantage.
• Working in an empathetic and empowering way.
• Working with databases and assimilating and reporting information.
• Experience of working in a dynamic and creative way, solving problems and prioritising work.

Desirable

• Experience of working in a multi-disciplinary team.
• Experience of gathering information to determine needs/expectations.

Skills and abilities

Essential

• Excellent administration skills.
• Telecommunication skills.
• High level communication and interpersonal skills.
• Excellent organisational skills with a logical and structured approach to your work.
• Ability to respond to changing needs, pressures and demands and prioritise accordingly.
• Strong IT skills to include EMIS and Microsoft office, in particular excel and word.
• Ability to build effective working relationships.
• Ability to analyse and interpret data.
• Evidence of working within a team environment.
• Maintaining boundaries and ensuring clarity and understanding of the role.
• Ability to self-manage and be creative in your approach to problem solving.
• Ability and confidence to work on own initiative.

Desirable

• Use of IT systems including EMIS, Care Notes, Microsoft office, email and database systems (external and internal).

Qualifications

Essential

• Good general standard of education

Desirable

• Administration related qualification

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

Vertis Health

Address

St. Martins Gate Surgery

Turnpike House Medical Centre

37 Newtown Road

WORCESTER

WR5 1EZ

United Kingdom

Employer's website

https://www.vertishealth.org.uk/ (Opens in a new tab)

Job description

Job responsibilities

• In accordance to the practice timetable, the post-holder will make themself available to undertake a variety of duties including surgery consultations, telephone consultations and queries, home visits, checking and signing repeat prescriptions and dealing with queries, paperwork and correspondence in a timely fashion.
• Making professional, autonomous decisions in relation to presenting problems, whether self-referred or referred from other healthcare workers within the organisation.
• Assessing the heathcare needs of patients with undifferentiated and undiagnoses problems.
• Screening patients for disease risk factors and early signs of illness
• In consultations with patients and in line with current practice disease management protocols, developing care plans for health.
• Providing counselling and health education
• Admitting or discharging patients to and from the caseload and referring to other care providers as appropriate
• Recording clear and contemporaneous consultation notes to agreed standards
• Collecting data for audit purposes
• Compiling and issuing computer-generated acute and repeat prescriptions
• Prescribing in accordance with the practice prescribing formulary whenever this is clinically appropriate.
• In general, the post-holder will be expected to undertake all normal duties and responsibilities associated with a GP working within primary care.

Person Specification

Qualifications

Essential

• Qualified GP
• MRCGP
• Vocational Training Certificate or equivalent JCPTGP
• General Practitioner (Certificate of Completion of Training CCT)
• Full GMC Registration
• National Performers List registration
• Appropriate defence indemnity (MPS/MDU)
• Eligibility to practice in the UK independently
• Experience of working in a primary care environment
• Experience of continued professional development
• Experience of QOF and clinical audit

Desirable

• Experience of medicines management
• Experience of ICB initiatives
• EMIS web
• General understanding of the GMS contract
• Disclosure and Barring Service Check

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.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Employer details

Employer name

St. Martin’s Gate Surgery

Address

Turnpike House Medical Centre

37 Newtown Road

Worcester

Worcestershire

WR5 1EZ

United Kingdom

Employer's website

https://www.stmartinsgatesurgery.co.uk/ (Opens in a new tab)