Frailty Care Coordinator Harrow East Primary Care Network (PCN)

Harrow East Primary Care Network (PCN) is seeking an enthusiastic, compassionate and highly organised Frailty Care Coordinator to join our friendly and forward-thinking multidisciplinary team.

This is an exciting opportunity to play a key role in supporting our established frailty service, working closely with the Frailty GP, Advanced Practitioners and wider healthcare professionals to improve the care and experience of older and vulnerable patients.

The successful candidate will support the coordination of care for patients living with moderate and severe frailty, ensuring appointments, referrals, multidisciplinary discussions and follow-up arrangements are managed effectively.

We are looking for a proactive individual with excellent organisational and communication skills who is passionate about delivering patient-centred care and helping patients remain safe, well and independent within their own homes and communities.

Main duties of the job

The Frailty Care Coordinator will provide dedicated administrative and care coordination support to the Frailty GP and wider multidisciplinary team across Harrow East PCN.

The role will involve coordinating appointments, home visits, referrals and follow-up reviews for patients identified as living with moderate or severe frailty, while maintaining accurate patient records and monitoring outstanding actions.

The postholder will organise and support multidisciplinary team (MDT) meetings, prepare agendas, record agreed actions and ensure these are appropriately followed up.

Working closely with GP practices, community healthcare services, hospitals, social care teams and other organisations, the successful candidate will support effective communication, timely referrals and continuity of care.

The role also involves communicating with patients, families and carers, escalating concerns appropriately and supporting the ongoing improvement of the PCN frailty service.

Key responsibilities

1. Frailty caseload coordination

• Provide dedicated administrative and care coordination support to the Frailty GP and wider frailty team.
• Support the organisation and monitoring of patients identified as living with moderate or severe frailty.
• Maintain accurate and up-to-date records of patients receiving support from the frailty service.
• Coordinate planned clinical reviews, appointments and home visits as directed by the clinical team.
• Monitor outstanding patient-related actions, ensuring appropriate follow-up and escalation where necessary.

1. Appointment, referral and follow-up management

• Arrange and coordinate patient appointments, home visits and follow-up reviews.
• Process and monitor referrals to community healthcare teams, social care services, rehabilitation services and other appropriate organisations.
• Follow up outstanding referrals and requests, ensuring progress is communicated to the relevant healthcare professional.
• Support timely coordination of post-discharge reviews and follow-up arrangements following hospital admission.

1. Multidisciplinary team coordination

• Organise and provide administrative support for frailty multidisciplinary team (MDT) meetings.
• Coordinate meeting arrangements, prepare agendas and collate relevant information.
• Maintain accurate records of discussions, decisions and agreed actions.
• Allocate or communicate actions to the relevant professionals in accordance with agreed processes.

1. Patient, family and carer communication

• Act as a point of contact for administrative queries relating to the frailty service.
• Communicate with patients, families and carers in a compassionate, professional and sensitive manner.
• Provide appropriate non-clinical information and signposting to relevant health, social care and community support services.

1. Clinical systems and information management

• Maintain accurate and timely patient records using EMIS Web and other relevant clinical systems.
• Support the processing of clinical correspondence, referrals and administrative tasks using approved systems.
• Use Microsoft Office, including Word, Excel, Outlook and Teams, to maintain trackers, prepare documents and communicate with colleagues.

1. Service development and improvement

• Contribute to the ongoing development and improvement of the Harrow East PCN frailty service.
• Identify opportunities to improve administrative processes, patient pathways and coordination between services.
• Support initiatives aimed at improving patient experience, continuity of care and access to appropriate services.

Confidentiality and information governance

The postholder will have access to confidential and sensitive information relating to patients, colleagues and healthcare professionals.

All information must be handled appropriately and in accordance with UK GDPR, the Data Protection Act 2018, NHS information governance requirements and organisational policies.

Safeguarding and patient safety

The postholder must recognise and appropriately escalate safeguarding concerns, patient safety issues and situations requiring urgent clinical attention.