Job description

Job responsibilities

Frailty Care Coordinator

Employer: Harrow East Primary Care Network (PCN)

Location: Harrow / Stanmore, London

Practice sites: Honeypot Medical Practice, Bacon Lane Surgery and Mollison Way Surgery

Salary: From £13.00ph, dependent on relevant experience and suitability against the person specification. Part-time salary calculated pro rata.

Hours: 37.5 hours per week (full-time), with part-time applications considered.

Contract: Fixed-term, with the possibility of extension.

Reports to: PCN Manager

Accountable to: PCN Clinical Director and PCN Practices

The Frailty Care Coordinator will play an important role in supporting the effective delivery of the Harrow East PCN frailty service, ensuring that patients living with moderate and severe frailty receive coordinated, timely and person-centred care.

Working closely with the Frailty GP and wider multidisciplinary team, the postholder will be responsible for coordinating appointments, referrals, multidisciplinary team meetings, patient follow-up and administrative processes associated with the frailty caseload.

The role will support the proactive management of vulnerable patients, helping to improve communication between healthcare professionals, patients, families and carers while promoting continuity of care across primary, community, secondary and social care services.

The postholder will be expected to demonstrate excellent organisational skills, take ownership of allocated administrative responsibilities and ensure outstanding tasks and actions are monitored and progressed appropriately.

1. Frailty caseload coordination

• Provide dedicated administrative and care coordination support to the Frailty GP and wider frailty team.

• Support the organisation and monitoring of patients identified as living with moderate or severe frailty.

• Maintain accurate and up-to-date records of patients receiving support from the frailty service.

• Coordinate planned clinical reviews, appointments and home visits as directed by the clinical team.

• Monitor outstanding patient-related actions, ensuring appropriate follow-up and escalation where necessary.

• Support the identification of patients requiring further review using established PCN processes and clinical guidance.

• Assist in maintaining effective systems for monitoring frailty caseload activity and service performance.

2. Appointment, referral and follow-up management

• Arrange and coordinate patient appointments, home visits and follow-up reviews.

• Process and monitor referrals to community healthcare teams, social care services, rehabilitation services and other appropriate organisations.

• Follow up outstanding referrals and requests, ensuring progress is communicated to the relevant healthcare professional.

• Support timely coordination of post-discharge reviews and follow-up arrangements following hospital admission.

• Liaise with patients, families and carers regarding appointments, referrals and administrative aspects of their care.

• Identify delays, incomplete actions or barriers to accessing services and escalate these appropriately.

• Ensure administrative tasks are completed accurately and within agreed timescales.

3. Multidisciplinary team coordination

• Organise and provide administrative support for frailty multidisciplinary team (MDT) meetings.

• Coordinate meeting arrangements, prepare agendas and collate relevant information.

• Maintain accurate records of discussions, decisions and agreed actions.

• Allocate or communicate actions to the relevant professionals in accordance with agreed processes.

• Monitor completion of outstanding MDT actions and follow up with responsible team members.

• Support effective communication between GPs, Advanced Practitioners, community teams, hospitals and social care professionals.

• Assist in improving the efficiency and effectiveness of multidisciplinary working across the frailty service.

4. Patient, family and carer communication

• Act as a point of contact for administrative queries relating to the frailty service.

• Communicate with patients, families and carers in a compassionate, professional and sensitive manner.

• Provide appropriate non-clinical information and signposting to relevant health, social care and community support services.

• Support patients in understanding appointment arrangements and accessing services.

• Recognise when concerns require clinical assessment or safeguarding escalation and promptly refer these to the appropriate professional.

• Maintain professional boundaries and ensure clinical advice and decisions remain the responsibility of appropriately qualified healthcare professionals.

5. Clinical systems and information management

• Maintain accurate and timely patient records using EMIS Web and other relevant clinical systems.

• Support the processing of clinical correspondence, referrals and administrative tasks using approved systems.

• Use Microsoft Office, including Word, Excel, Outlook and Teams, to maintain trackers, prepare documents and communicate with colleagues.

• Ensure information is recorded, updated and shared appropriately in accordance with confidentiality and information governance requirements.

• Monitor administrative workflows and highlight incomplete tasks, delays or operational concerns.

• Support the collection and reporting of relevant frailty service activity and performance information.

6. Service development and improvement

• Contribute to the ongoing development and improvement of the Harrow East PCN frailty service.

• Identify opportunities to improve administrative processes, patient pathways and coordination between services.

• Support initiatives aimed at improving patient experience, continuity of care and access to appropriate services.

• Assist with service audits, activity monitoring and quality improvement projects.

• Work collaboratively with the PCN Manager and frailty team to develop effective and sustainable working processes.

• Support the achievement of relevant PCN objectives and service priorities.

The postholder will have access to confidential and sensitive information relating to patients, colleagues and healthcare professionals.

All information must be handled appropriately and in accordance with UK GDPR, the Data Protection Act 2018, NHS information governance requirements and organisational policies.

The postholder must maintain confidentiality at all times and ensure patient information is only accessed, recorded and shared for legitimate professional purposes.

The postholder must recognise and appropriately escalate safeguarding concerns, patient safety issues and situations requiring urgent clinical attention.

The Frailty Care Coordinator is a non-clinical role and must not undertake independent clinical assessments, provide clinical advice or make clinical decisions outside their responsibilities.

Appropriate training and support will be provided in line with organisational requirements.

The postholder will receive line management support from the PCN Manager and work closely with the Frailty GP and wider clinical team.

They will be expected to participate in relevant training, supervision and development opportunities, maintain their knowledge of organisational processes and take an active role in improving their skills and performance.

The postholder will be expected to:

• Demonstrate a professional, compassionate and patient-centred approach.

• Work collaboratively with colleagues across all three PCN practices.

• Manage their workload effectively and meet agreed deadlines.

• Maintain accurate records and take responsibility for allocated tasks.

• Comply with organisational policies, procedures and mandatory training requirements.

• Promote equality, diversity and inclusion in all aspects of their work.

• Undertake other reasonable duties consistent with the nature and level of the role.

This job description provides an outline of the principal duties and responsibilities and may be reviewed in accordance with changing service needs, following appropriate discussion with the postholder.

• Company pension

• Free on-site parking

• Supportive multidisciplinary working environment

• Opportunities for training and professional development

Person Specification

Qualifications

Essential

• -GCSEs (Grade 4/C or above) in English Language and Mathematics, or equivalent qualifications
• -Good standard of general education and IT literacy
• -Willingness to undertake mandatory training and continuing professional development

Desirable

• -Qualification in health and social care, business administration or a related field
• -Care Coordinator training or relevant vocational qualification
• -Additional training in frailty, dementia care, safeguarding or personalised care

Experience

Essential

• -Previous experience in an administrative, coordination or patient-facing support role
• -Experience organising appointments, managing administrative tasks and following up outstanding actions
• -Experience communicating with a range of professionals, service users or external organisations
• -Experience maintaining accurate records and handling confidential information
• -Experience using Microsoft Office applications
• -Experience managing competing priorities and working to deadlines

Desirable

• -Experience working in an NHS, GP practice or Primary Care Network setting
• -Experience working with older, frail or vulnerable patients
• -Experience supporting multidisciplinary team meetings
• -Experience coordinating referrals, home visits or hospital discharge follow-up
• -Experience using EMIS Web, AccuRx or other NHS clinical systems
• -Experience working alongside community healthcare or social care services

Knowledge and Skills

Essential

• -Excellent organisational and time management skills
• -Strong written and verbal communication skills
• -Ability to coordinate multiple tasks, follow up outstanding actions and maintain accurate records
• -Good IT skills, including Word, Excel, Outlook and Teams
• -Ability to communicate effectively and sensitively with patients, families and carers
• -Understanding of confidentiality, data protection and professional boundaries
• -Ability to recognise concerns that require escalation to an appropriate professional
• -Ability to work independently, use initiative and solve problems effectively
• -Ability to maintain attention to detail and complete process-driven tasks accurately

Desirable

• -Understanding of frailty and the challenges faced by older and vulnerable patients
• -Knowledge of local health, social care and community support services
• -Knowledge of NHS referral pathways and multidisciplinary care coordination
• -Experience preparing MDT agendas, recording minutes and monitoring actions
• -Understanding of personalised care and proactive case management
• -Familiarity with clinical administration processes and NHS terminology

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

Honeypot Medical Centre

Address

Honeypot Medical Centre - Charlton Annexe

223 Charlton Road

Kenton

Harrow

Middlesex

HA3 9HT

United Kingdom

Employer's website

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