Network Care Coordinator - Frailty Care Coordination MDT Pilot

Key responsibilities of the post:

1. Identify residents who would benefit from a Proactive Care approach: Coordinate the list of residents aged 65+, moderately frail, with COPD/CVD, frequent hospital attendees, for MDT support. Develop a Personalised Care and Support Plan for each, using EMIS. Cross-reference lists with patient records to understand involved professionals. Prioritise the cohort list with practitioners. Work to increase awareness of vulnerable households and patients needing support.
2. Discuss with residents: Explain the proactive care offer, invite involvement, conduct holistic assessments, and build trust. Communicate with the frailty and long-term conditions team regarding health outcomes or further assessments.
3. Be a core part of Network Team MDTs: Lead and support effective meetings, organise monthly locality frailty MDT meetings, and attend neighbourhood meetings. Discuss patients for proactive care pathways and involve relevant professionals in MDT discussions.
4. Coordinate support for residents: Help manage needs, access training, employment, benefits, and self-management education. Signpost to health services and work with local authorities on wider determinants of health.
5. Maintain good record keeping: Keep accurate, confidential, and up-to-date documentation in EMIS, including safeguarding. Update MDT records and follow-up actions, and monitor reporting templates.
6. Evaluate outcomes: Support residents in understanding their health and wellbeing, gather data and stories, and report on outcomes and activities.
7. Leadership: Champion proactive care delivery within the neighbourhood, coordinate with practices, and update management on progress and concerns.
8. Working with others: Build relationships across services, attend meetings, and contribute to team improvement.
9. Supervision and training: Engage in available training and undertake courses with the Personalised Care Institute.