LS25/26 PCN Proactive Frailty Care Coordinator

Job summary

The Care Coordinator role is seen as a critical and evolving post to support [the Enhanced Health in Care Homes (EHCH) Multi-Disciplinary Teams within the locality to deliver effective, coordinated care for vulnerable and frail adults, particularly those at high risk of a hospital emergency admission, ED attendances or out of hours care.To proactively coordinate personalised care and support planning for the most vulnerable people in the community, focussing on the frail/elderly and those with other long-term health conditions.

To meet with people, families and carers (in the practice, in their home and in other community settings) to co-ordinate their care, review their needs and help them access the services and support they require, assisting them to understand and manage their own health and wellbeing referring to other professionals where appropriate.

Main duties of the job

Act as a central point of contact to ensure that patients receive the best possible care, and the person is supported to achieve the outcomes that are important to them. This is achieved by bringing together all the information about a persons identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.

To support people in preparing for or following-up clinical conversations they have with primary care professionals to enable them to be actively involved in managing their care and supported to make choices that are right for them. You will use knowledge of health and social services available in the locality, including those offered by the community and voluntary sector, to link people up with these and help them overcome any barriers they might encounter. The aim is to help people improve their quality of life and avoid unplanned hospital admissions.

The Care Coordinators role will support the frailty team and Multi-Disciplinary Team in coordinating all key activity including access to services, advice, and information, helping them to live well at home. This role will also include some clinical aspects, such as observations, venepuncture, skin checks etc.

About us

LS25/26 PCN has a patient population of approximately 77,500 across 7 practices. We aim to provide high quality services adhering to principles of best practice, promoting equal opportunities, and working positively with diversity.

Details

• Date posted: 24 August 2026
• Pay scheme: Other
• Salary: £25,009 a year Pro Rata
• Contract: Fixed term
• Duration: 2 years
• Working pattern: Part-time, Flexible working
• Reference number: U0053-26-0027
• Job locations: Hosted Empolyers address, 1st Floor Park Edge Practice, Asket Drive, Leeds, West Yorkshire, LS14 1HX, United Kingdom

Job responsibilities

DUTIES AND AREAS OF RESPONSIBILITY:

• Support the PCN in bringing together all of a patients identified care and support needs and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the patient. This may include having a caseload of patients.
• Support the PCN in improving overall patient care through promotion of services available to them locally within the PCN and the wider health system
• Support the frailty team in identifying appropriate patient cohorts for targeted intervention
• Partake in multidisciplinary meetings across local care organisations identifying patients in need of review and collating any information required to facilitate their review prior to the meeting.
• Provide admin support to multidisciplinary meetings including taking minutes.
• Liaise with other key stakeholders as needed for the collective benefit of the patient including but not limited to GPs, nurses, pharmacists, and other support staff from within the PCN practices or from other provider organisations
• Undertake delegated clinical procedures within own skills and competence when required (depending on experience and qualifications)
• Assist patients and carers in managing their own needs, answering their queries, and supporting them to address their needs
• Communicate effectively and sensitively using language appropriate to the patient and their carer and their level of understanding
• Provide accurate, impartial information, support and guidance to patients and their carers to enable them to make choices about their care
• Raise awareness of shared decision making and decision support tools, and assist patients to be more prepared for shared decision-making conversations
• To provide coordination and navigation for patients and their carers across health and social care services, where appropriate linking with professionals from the MDT
• Work in partnership with key providers in the local community to enable improved access to services for patients
• Support patients to self-manage conditions. Support patients to access appropriate benefits where eligible
• Actively engage with, assist and provide advice to carers, to enable them to sustain their caring role escalating any concerns to the practice when required
• Work with practices to support delivery of any national and local targets with regard to the GP contract e.g. PCN DES
• Engage in delegated clinical tasks including but not limited to, venepuncture, observation monitoring, measuring, and ordering equipment, ear checks, supporting patients to manage e.g. inhaler technique
• Supporting families and carers to help effectively support the patient.

SAFEGUARDING

• Identifies and takes appropriate safeguarding action when required in line with local policies
• Support the practices in safeguarding processes, knowing when to intervene. Ensuring patients are protected from harm, while protecting their human rights.
• Alert your line manager of any significant changes or events which relate to safeguarding
• Support safeguarding investigations where required

OTHER RESPONSIBILITIES

• To assist the PCN Clinical Director(s) and board in setting and realising the PCN vision, mission, and business strategy.
• To play a role in the delivery of high-quality primary health care service.
• Maintain a working relationship with local health care providers enable service delivery and mutual benefit and build a network and knowledge of referral routes to and from service providers.
• To establish and maintain effective liaison with stakeholders including health, voluntary, social and education resources, attending relevant meetings as necessary
• Collate feedback/analysis data on behalf of the PCN to report to the PCN Board and CCG/NHSE as required
• Support the PCN Operational Manager in providing Key Performance Indicator (KPI) reports for submission as requested.
• Work in partnership with local providers and community groups to improve collaboration, co-ordination of care and support to the local population
• Attendance and contribution at relevant community meetings to represent the frailty team when required.
• Be responsible for the organisation, planning of own workload to meet set deadlines.
• Following PCN and practice policies and procedures as appropriate.

KEY WORKING RELATIONSHIPS

• Frailty MDT
• Local Neighbourhood Team
• GP Practices with the PCN
• Practice Leaders (Partners and Practice Managers)
• PCN Social Prescribing
• Health and wellbeing team
• PCN Clinical Pharmacists
• PCN Clinical Director(s) and Operational Manager
• Adult Social Care
• Third sector partners