Join to apply for the PCN Frailty Care Coordinator role at Tenzing Health
Job Summary
You start the day reviewing your caseload. Each name is someone whose health journey you're helping to support. By mid-morning, you might be speaking with a patient's family, coordinating a clinical review, or helping someone navigate support for a new diagnosis. Every call, every conversation is a step toward making care feel more personal, connected, and manageable.
As a Care Coordinator for frailty at Worcester City PCN, you're the friendly, reliable bridge between patients and the wider healthcare system. You'll work closely with GPs, clinical teams, social prescribers, and pharmacists to ensure that people living with frailty get the right care at the right time. You'll be the consistent voice checking in, coordinating appointments, building personalised care plans, and ensuring patients and their carers never feel left behind.
This role is about compassion, communication, and practical coordination. You'll be key to helping people stay independent for longer, with more confidence in managing their health. If you're organised, empathetic, and thrive on making a difference in someone's day, this could be your perfect next step in primary care.
Main duties of the job
* Act as a key point of contact for patients living with frailty, helping them navigate health and care services with confidence
* Coordinate care across the PCN linking patients with GPs, pharmacists, social prescribers, and other professionals
* Work with patients, families, and carers to co-create personalised care plans that reflect individual needs and goals
* Support patients after hospital discharge or during times of declining health by ensuring timely reviews and follow-ups
* Run clinical system searches to identify patients needing care coordination, and proactively reach out to offer support
* Help patients access the right appointments, services, and resources answering queries and signposting as needed
* Contribute to improving outcomes in frailty care by capturing and analysing patient data, and supporting service audits
* Stay informed on national and local frailty strategies and apply these in day-to-day practice
* Collaborate closely with GP practices across Worcester City PCN to ensure care is joined-up and consistent
* Support a culture of continuous improvement by contributing ideas and helping implement changes to enhance care delivery
* Maintain accurate, timely patient records using EMIS and other systems, always respecting confidentiality and GDPR
* Work flexibly including occasional home or care home visits to ensure patients are supported where and when they need it most
About Us
Vertis Health is a fast-growing provider of community-based healthcare services to NHS patients within South Worcestershire. The organisation utilises the excellent clinical expertise that already resides within the local NHS environment and harnesses it with efficient administration pathways to provide patients with more convenient and accessible services. We hope that by doing this we will not only deliver pathway improvements to patients but also go some way to relieving the growing volume pressures that are being experienced within local hospitals and GP practices.
Job Description
As a Care Coordinator focused on frailty, you will work as a key part of the PCN multi-disciplinary team. You will be the key link to the people whose care you are supporting, operating as a go-to person to ensure that their care is seamless. You will be working as an advocate for patients who are struggling with their declining health. Care coordinators play an important role within a PCN to proactively identify and work with people, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services.
You will work closely with the Clinical Leads and other primary care professionals within Worcester City PCN to identify and manage a caseload of identified patients, making sure that appropriate support is made available to them and their carers, and ensuring that their changing needs are addressed.
This will include achieving and exploring all options of support, assisting them to access services and identify any support they require. All patients on your caseload will receive a personalised care and support plan.
Key Duties & Responsibilities:
* Provide coordination and navigation for people and their carers across health and care services, working closely with primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate support.
* Work sensitively with people, their families, and carers to improve their understanding of the patient's condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes.
* Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care.
* To be able to manage a patient's needs appropriately documenting all consultations within the patient's notes.
* Listen to patients' needs and help to manage their needs through answering queries and signposting to the relevant services.
* Contact and organise clinical reviews for all patients with a new diagnosis or declining health with a GP/ACP/paramedic where appropriate.
* Liaise with appropriate GPs and professionals when appropriate.
* Build effective relationships with each practice and its staff.
* To run weekly clinical system searches for frailty patients contacting the patient to arrange appointments.
* Contribute to increasing performance of NHS contracts
* Contribute to the evaluation of the service, collate and input timely data, and suggest/implement service improvements.
* Keeping up to date with National/Local Frailty Strategies.
* Ability to work within a team and independently.
* Undertake any other duties deemed appropriate by the PCN Manager and clinical teams.
* Complete annual mandatory training as required.
* Enrol as a member of the Personalised Care Institute to receive up-to-date training and the opportunity to join webinars.
* Participation in an annual individual performance review, including taking own responsibility for maintaining record of own personal record.
Provide Personalised Support:
* Work with the patient, their families, and carers and consider how they can all be supported by services available to them.
* Bring together a person's identified care needs and explore their options to meet these within a simple coproduced personalised care and support plan, including what they can expect from the groups, activities, and services they are being connected to and what the person can do for themselves to improve their health and wellbeing.
* Seek advice and support from the Clinical Leads and/or identified individual(s) to discuss patient-related concerns (referring the patient back to the GP or other suitable health professional if required).
Apply as early as possible as we may close the job advert early if we receive a sufficient number of applications.
Please note the job location may be subject to change due to the nature of PCN work.
Person Specification
Qualifications
Essential
* Good general standard of education (e.g. GCSEs or equivalent)
Desirable
* Administration-related qualification (e.g. NVQ in Business Admin or equivalent)
* Care Coordinator Formal Qualification
* Health and Social Care Qualification
Experience
Essential
* Significant experience in an administrative or coordination role, ideally with a proactive approach
* Experience working in health, social care, or a related front-facing environment
* Confidence in working with vulnerable individuals or those facing disadvantage
* Skilled at working empathetically and supportively with patients and carers
* Proficient in using databases and digital systems to manage and report information
* Experience of problem-solving and managing a varied, often reactive workload
* Working knowledge of confidentiality, safeguarding, and diversity principles
* Self-motivated, adaptable, and able to work both independently and within a team
Desirable
* Experience working in a multi-disciplinary team (e.g. alongside clinicians or care providers)
* Familiarity with care planning, personalised care, or case management
* Experience gathering information to determine patient needs and expectations
* Knowledge of social and health care systems and processes
* Understanding of relevant legislation, including Data Protection, safeguarding, and GDPR
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: SW Healthcare
Address: Henwick Halt Medical Centre, 1 Ingles Drive, Worcester, WR2 5HL
Employer's website: http://www.swhealthcare.org.uk
Seniority level
Entry level
Employment type
Part-time
Job function
Other
Industries
Hospitals
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