Neighbourhood Frailty Care Coordinator


Company:	NHS Jobs
Salary:	from £30,562 a year
Hours:	Full-time
Location:	Northallerton, DL6 2NQ
Job type:	Permanent
Posting date:	27 Oct 2026
Closing date:	25 Nov 2026

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Summary

The Neighbourhood Frailty Care Coordinator plays a pivotal role in the delivery of the Hambleton and Richmondshire Proactive Frailty Model, providing operational coordination across neighbourhood multidisciplinary teams (MDTs). Working in partnership with General Practice, Community Services, Adult Social Care, Mental Health, Medicines Optimisation, VCSE organisations and other system partners, the post holder will coordinate Neighbourhood MDTs, support proactive population health management and facilitate integrated care planning and delivery. The role is non-clinical and focuses on operational and service coordination, Individual patient pathway integration, quality improvement and performance monitoring to improve outcomes for people living with frailty and support the delivery of integrated neighbourhood care. MAIN DUTIES AND RESPONSIBILITIES Facilitation The post holder will: Facilitate and, where necessary, chair Neighbourhood MDT meetings in partnership with the clinical lead/practice clinicians, ensuring discussions remain focused on proactive care planning, coordinated actions and agreed patient outcomes. Coordinate all aspects of the MDT process, including meeting planning, patient identification, agendas, supporting documentation, meeting logistics and follow-up activity, enabling clinical leads to focus on clinical decision-making. Gather and present relevant patient information and coordinate appropriate professional representation to support informed multidisciplinary discussion and collaborative decision-making. Ensure discussions always keep the patient at the centre of consideration, taking account of their needs, wishes and circumstances. Facilitate inclusive and outcome-focused MDT discussions, ensuring decisions, actions, responsibilities and timescales are clearly recorded, communicated and monitored through to completion. Act as the operational coordinator and first point of contact for GP practices and partner organisations in relation to Neighbourhood MDT processes, providing advice and support to promote effective and consistent delivery. Maintain robust processes for the secure receipt, management and sharing of patient information in accordance with Information Governance, Data Protection and organisational requirements. Remain mindful of allotted time by encouraging concise, focussed discussion to ensure meetings are effective. Population Health Management The post holder will: Utilise agreed population health management tools, clinical systems and reporting dashboards to support proactive case finding and identify individuals who may benefit from multidisciplinary review or early intervention. Analyse agreed frailty and deterioration indicators, including hospital admissions, Emergency Department attendances, falls and other locally agreed triggers, to support identification and prioritisation of individuals at increased risk. Develop, maintain and regularly review neighbourhood frailty cohorts, patient tracking systems and frailty registers, supporting General Practice to maintain accurate coding, recording and data quality. Coordinate the identification and prioritisation of patients for Neighbourhood MDT discussion, ensuring those with the greatest complexity, risk or unmet need are reviewed in a timely manner. Maintain operational oversight of the neighbourhood frailty caseload, working with General Practice and system partners to coordinate multidisciplinary assessment, personalised care planning, pathway progression and escalation to the Integrated Neighbourhood Team (INT) where appropriate. Care Coordination The post holder will: Coordinate the implementation of agreed actions arising from Neighbourhood MDT discussions, ensuring responsibilities are clearly communicated, progressed within agreed timescales and reviewed through subsequent MDT meetings where appropriate. Work collaboratively with General Practice, Community Services, Adult Social Care, Mental Health, Medicines Optimisation, VCSE organisations and other partner agencies to coordinate timely referrals, assessments, actions and ongoing service involvement, ensuring patients receive seamless, coordinated care. Maintain operational oversight of patients progressing through the Neighbourhood Frailty Model, ensuring agreed actions are implemented, monitored and reviewed, and supporting timely escalation to the Integrated Neighbourhood Team (INT) or other appropriate services where required. Act as an accessible point of contact for patients and carers where appropriate, providing information, facilitating communication between organisations and supporting engagement with agreed care plans, services and actions. Promote effective communication and information sharing between professionals, working collaboratively to resolve barriers, support continuity of care and reduce unnecessary duplication. Service Improvement, Performance and Evaluation The post holder will: Identify opportunities to improve operational processes, MDT effectiveness and patient outcomes, working with practices and partner organisations to develop and implement practical solutions. Support the development, implementation and review of standard operating procedures, operational guidance, pathways and agreed ways of working across the Proactive Frailty Model. Promote consistency and continuous improvement across neighbourhoods by sharing learning, good practice and supporting the adoption of new ways of working. Develop and maintain, with appropriate support, neighbourhood frailty dashboards, KPI tracking systems, patient tracking systems and operational performance information to meet agreed reporting requirements. Monitor and report on MDT activity, patient pathways, outcomes and agreed performance measures, supporting audit, evaluation and quality improvement through the collection and analysis of operational data. Identify and escalate emerging risks, variation, data quality or performance concerns through appropriate governance arrangements and support agreed improvement actions. Relationships and Communication The post holder will be expected to: Build and maintain effective working relationships with General Practice, Community Services, Adult Social Care, Mental Health, Medicines Optimisation, VCSE organisations, Secondary Care and other partner agencies to support integrated neighbourhood working. Act as the key operational link between partner organisations, facilitating effective communication, information sharing and collaborative problem-solving to support coordinated, person-centred care. Promote partnership working and joint decision-making, ensuring effective communication between organisations and supporting continuity of care across the neighbourhood pathway. Develop positive relationships with patients and carers, ensuring they remain at the centre of care planning and service delivery where appropriate. Represent the Neighbourhood Frailty Model positively across partner organisations, promoting engagement, consistency, innovation and continuous improvement.

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