Job summary The postholder will work closely with the PCN Frailty Lead and the PHM Clinical Frailty Practitioner. He/she will work with the wider PCN team and across an integrated neighbourhood team of different health and care professionals involved in the care of this group of patients to coordinate their care plans. This role involves patient facing care, and the post holder will be responsible for providing support directly to patients and their carers. The post holder will also act as a conduit for patients within the PCN, liaising with GPs, district nurses, therapists, physios, adult social care, voluntary sector, and other PCN colleagues. Main duties of the job Main Duties and Responsibilities Help people to manage their needs through answering queries and ensuring that people have good quality written or verbal information to help them make choices about their care. Own a list of potential patients across the PCN practices who are over 65 with mild and moderate frailty. Contact patients on the list to enrol them in the programme and triage them into a pathway depending on their response to a questionnaire, working closely with a the Clinical Frailty Practitioner. Support the ongoing case management of patients on this pathway through regular check-ins and respond to any significant eventse.g. hospital admission, as well as supporting them to ensure their patient-centred care plan is regularly reviewed. Work closely with multiple professionals from across the sectors to coordinate the patients care and ensure they are receiving the help and support they need. Support the PCN on implementation of the programme by working within governance structures and providing feedback and iteration of the model. For Further Information see attached Job Description. About us Oldham North Primary Care Network (PCN) is a network of four GP Practices lying within the Oldham Integrated Care System. Oldham North PCN services a population of around 43,000 patients and covers the Royton, Shaw and Crompton areas of Oldham. As a PCN, we are looking to grow our team of professionals focusing on a new population health management programme to support more proactive and holistic care for people with mild to moderate frailty. Date posted 12 February 2025 Pay scheme Agenda for change Band Band 4 Salary Depending on experience Contract Fixed term Duration 12 months Working pattern Full-time Reference number A3504-25-0001 Job locations Royton Health & Wellbeing Centre Park Street Royton Oldham OL2 6QW Job description Job responsibilities Main Duties and Responsibilities Help people to manage their needs through answering queries and ensuring that people have good quality written or verbal information to help them make choices about their care. Own a list of potential patients across the PCN practices who are over 65 with mild and moderate frailty. Contact patients on the list to enrol them in the programme and triage them into a pathway depending on their response to a questionnaire, working closely with a the Clinical Frailty Practitioner. Support the ongoing case management of patients on this pathway through regular check-ins and respond to any significant events e.g. hospital admission, as well as supporting them to ensure their patient-centred care plan is regularly reviewed. Work closely with multiple professionals from across the sectors to coordinate the patients care and ensure they are receiving the help and support they need. Support the PCN on implementation of the programme by working within governance structures and providing feedback and iteration of the model. Maintain a log that records the journey of each patient on the PHM programme, including the services they are referred to. Identify where there may be health inequalities and provide feedback on where engagement could be enhanced. Support improvement of information recording on patients across the PCN, including coding for these patients in EMIS and the Greater Manchester Shared Care Record Work closely with Care Co-ordinators across other Oldham PCNs who are implementing PHM pathways focussed on frailty to support integration of care across organisational boundaries. RESPONSIBILITIES TO PCN TEAMS Actively develop effective working relationships and lines of communication within the practice, with the PCN, and with wider multi-professional teams across the PCN e.g. Social Prescribers, Pharmacists and other clinical/non-clinical partners involve in the patients care. Demonstrate ability to work effectively as a member of a team with the practice, PCN and Clinical Frailty Practitioner as a key person within the PHM model. Recognise personal limitations and refer to more appropriate colleague(s) when necessary. Follow through with service users and others involved to ensure all services and care arrangements are in place. Develop an in-depth knowledge of local health and care infrastructure and knows how and when to enable people to access support and services that are right for them. RESPONSIBILITIES TO PATIENTS Manage a caseload of patients with mild and moderate frailty within the PCN. Support patients to utilise decision aids in preparation for a shared decision-making conversation. Proactively check in with patients on the case load to help manage their needs through answering queries and ensuring that people have good quality written or verbal information to help them make choices about their care. Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing. Job description Job responsibilities Main Duties and Responsibilities Help people to manage their needs through answering queries and ensuring that people have good quality written or verbal information to help them make choices about their care. Own a list of potential patients across the PCN practices who are over 65 with mild and moderate frailty. Contact patients on the list to enrol them in the programme and triage them into a pathway depending on their response to a questionnaire, working closely with a the Clinical Frailty Practitioner. Support the ongoing case management of patients on this pathway through regular check-ins and respond to any significant events e.g. hospital admission, as well as supporting them to ensure their patient-centred care plan is regularly reviewed. Work closely with multiple professionals from across the sectors to coordinate the patients care and ensure they are receiving the help and support they need. Support the PCN on implementation of the programme by working within governance structures and providing feedback and iteration of the model. Maintain a log that records the journey of each patient on the PHM programme, including the services they are referred to. Identify where there may be health inequalities and provide feedback on where engagement could be enhanced. Support improvement of information recording on patients across the PCN, including coding for these patients in EMIS and the Greater Manchester Shared Care Record Work closely with Care Co-ordinators across other Oldham PCNs who are implementing PHM pathways focussed on frailty to support integration of care across organisational boundaries. RESPONSIBILITIES TO PCN TEAMS Actively develop effective working relationships and lines of communication within the practice, with the PCN, and with wider multi-professional teams across the PCN e.g. Social Prescribers, Pharmacists and other clinical/non-clinical partners involve in the patients care. Demonstrate ability to work effectively as a member of a team with the practice, PCN and Clinical Frailty Practitioner as a key person within the PHM model. Recognise personal limitations and refer to more appropriate colleague(s) when necessary. Follow through with service users and others involved to ensure all services and care arrangements are in place. Develop an in-depth knowledge of local health and care infrastructure and knows how and when to enable people to access support and services that are right for them. RESPONSIBILITIES TO PATIENTS Manage a caseload of patients with mild and moderate frailty within the PCN. Support patients to utilise decision aids in preparation for a shared decision-making conversation. Proactively check in with patients on the case load to help manage their needs through answering queries and ensuring that people have good quality written or verbal information to help them make choices about their care. Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing. Person Specification Person Specification Essential See Attached Desirable See Attached Experience Essential See Attached Desirable See Attached Qualifications Essential See Attached Information Person Specification Essential See Attached Desirable See Attached Person Specification Person Specification Essential See Attached Desirable See Attached Experience Essential See Attached Desirable See Attached Qualifications Essential See Attached Information Person Specification Essential See Attached Desirable See Attached 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 The Royton and Crompton family practice Address Royton Health & Wellbeing Centre Park Street Royton Oldham OL2 6QW Employer's website https://www.roytonandcromptonpractice.co.uk/ (Opens in a new tab)