PCN Care Coordinator - Frailty


Company:	NHS Jobs
Salary:	from £27,452.08 a year
Hours:	Full-time
Location:	WORCESTER, WR5 1EZ
Job type:	Permanent
Posting date:	21 Sept 2026
Closing date:	5 Oct 2026

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Summary

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. Key Responsibilities: 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.

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