Integrated Care - Frailty Care Coordinator

Take overall responsibility for coordination and delivery of the MDT meetings. A key role of the Care Coordinator will be to schedule the MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members in advance of the meeting. Utilise population health intelligence and PCN / Partner data to proactively identify and work with a cohort of patients to deliver personalised care. Support patients to utilise decision aids in preparation for a shared decision-making conversation. Holistically bring together all of a persons identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person. 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. Support people to take up training and employment, and to access appropriate benefits where eligible. Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing. Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level. Explore and assist people to access personal health budgets where appropriate. Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals. Work with the GPs and other primary care professionals within the practice to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals. Raise awareness of how to identify patients who may benefit from shared decision
making and support staff and patients to be more prepared to have shared decision-making conversations.