PCN Frailty Care Co-ordinator



  • Job Title: PCN Frailty Care Co-ordinator
  • Responsible to: Healthwest PCN Board
  • Accountable to: PCN Manager
  • Location: Hybrid working from home and practice
  • Hours: 37.5hrs
  • Remuneration: £21,500-£24k FTE depending on skills & experience
  • Contract Type: Permanent

Healthwest PCN is a mature Primary Care Network in the heart of Bristol, comprising Pembroke Road Surgery, The Family Practice, The Student Health Service and Whiteladies Health Centre.

We are looking for a highly motivated individual to join our small, friendly team of Care Coordinators, who are helping us to address health inequalities for our patients. This includes aiding patients to access our services and overcome any barriers to receiving the best possible healthcare and support.

You will be the first point of contact for our frail patients when they are discharged from hospital, ensuring that the care plan they have in place meets their needs, and arranging any appointments that they may need post discharge, e.g., a pharmacist appointment to discuss changes to their medication.

You will receive referrals from other health care staff to aid patients to access services, ensuring health and care planning is timely, efficient, and patient-centred. You will build relationships with our more vulnerable and complex patients to better understand their needs, enabling you to signpost them to the relevant services.

The role includes supporting digital initiatives while coordinating and navigating the patients’ journey through primary care. A key part of the role includes regular liaison with community services, transport services and other outside providers, and keeping up to date on all local service provisions.

The candidate will need to be an excellent communicator and be able to establish efficient monitoring and quality assurance systems. Training and support will be provided to successful applicants.


Roles and Responsibilities

  • To work with the GPs and other primary care professionals within the PCN to proactivelyidentify and work with a cohort of patients to deliver personal care.
  • To work closely and in partnership with the Social Prescribing Link Workers (SPLWs) and the wider Community Services including Sirona, to explore care options based on what matters to the person.
  • Pro-actively build relationships with outside providers to ensure good signposting for patients to access additional services.
  • To support patients to utilise decision aids in preparation for a shared decisions-making conversation and to help create single personalised care and support plans, in line with best practice.
  • To help people 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. This may include supporting people to take up training and employment, self-management education courses and access appropriate benefits where eligible.
  • To support people to understand their level of knowledge, skills and confidence (their “Activation” level) when engaging with their health and wellbeing, by utilising the Patient Activation Measure.
  • Being an initial contact point for ward rounds with nursing and residential homes, involving GP where needed
  • Support and feed into the development of the MDT approach to working with our patients
  • Becoming a contact point for patients who are:
    • Complex and or frail
    • Frequent visitors to the GP
    • Recently discharged from hospital or about to be discharged
    • Recently attended A and E and would benefit from follow up 
    • New patients to our list with follow up requirements 
    • Requiring active signposting to self-care services as part of on the day and minor illness approach 
  • Issue patient questionnaires and update responses into EMIS, identifying any patients who require additional support. 

Person Specification

Qualifications and Experience

  • Evidence of a sound education to A level standard or equivalent
  • Evidence of a commitment to continuing professional development
  • Administrative support experience
  • Experience and success of communicating with people
  • Experience of working in teams; able to promote teamwork 
  • Working in a computer environment

Knowledge and Understanding

  • Relevant knowledge of Primary Care Networks, General Practice and the wider Health and Social Care policies
  • An appreciation of the NHS agenda and Government targets

Skills and Competencies

  • Computer literate with an ability to use EMIS (desirable) and Microsoft office packages (essential) 
  • Understand the aims of current healthcare policy within the PCN 
  • Able to analyse, interpret and present data 
  • Has attention to detail, able to work accurately
  • Has a planned and organised approach with an ability to prioritise their own workload to meet strict deadlines 
  • Able to think analytically; anticipating obstacles and thinking ahead; using analytical techniques to draw logical solutions to problems 
  • Excellent communication skills, verbal and written, with the ability to adjust communication style and content to suit the audience 
  • Excellent verbal and written communication skills with team members and other healthcare professionals. Whilst recognising people’s needs for alternative methods of communication 
  • An excellent understanding of data protection and confidentiality issues 


  • Works effectively independently and as a member of a team 
  • Continued commitment to improve skills and ability in new areas of work
  • Self-motivated and proactive 
  • Able to undertake the demands of the post with reasonable adjustments if required 
  • Independently mobile to be able to work across several sites and travel to meet with stakeholders 
  • Adaptability, flexibility and ability to cope with uncertainty and change 
  • Demonstrate ability to work in a busy environment; ability to deal with both urgent and important tasks
  • Excellent time keeping and prioritisation skills 


The postholder will:

  • Develop a culture that promotes equality and values diversity. The postholder must be aware of and committed to the Equality and Diversity policies of the appointing GP Practice and comply with all the requirements of these policies and actively promote Equality and Diversity issues relevant to the post.
  • Ensure the principles of openness, transparency and candor are observed and upheld in all working practices.
  • The post holder will have, or acquire through training provided by the organisation, the appropriate level of safeguarding and knowledge, skills and practice required for the post and be aware of and comply with the organisation’s safeguarding protection policies and procedures.
  • Ensure that any infection prevention and control issues are reported to the line manager/Infection Prevention and Control Lead.

Equality and Diversity

The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:

  • Acting in a way that recognises the importance of people’s rights, interpreting them in a way that is consistent with practice procedures and policies, and current legislation
  • Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues
  • Behaving in a manner which is welcoming to and of the individual, is non-judgmental and respects their circumstances, feelings priorities and rights.

Personal/Professional Development:

The post-holder will participate in any training programme implemented by the practice as part of this employment, with such training to include:

  • Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development
  • Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work


The post-holder will strive to maintain quality within the practice, and will:

  • Alert other team members to issues of quality and risk
  • Assess own performance and take accountability for own actions, either directly or under supervision
  • Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the team’s performance
  • Work effectively with individuals in other agencies to meet patients’ needs
  • Effectively manage own time, workload and resources