Enhanced Frailty Health and Social Care Coordinator

• Work with GP Surgeries to identify potential referrals to the Tier 2 Frailty Service
• Working with Frailty Team colleagues, use risk stratification tools to identify patients at risk and ensure they receive assessment and care in a timely fashion
• Support the Frailty Team in the delivery of Complex Care, coordinating care delivery between service providers as needed
• Make Social Prescribing referrals, as appropriate
• Contribute to planned team huddles and multi-disciplinary team meetings
• Hold regular welfare calls with the patient / carer
• Maintain excellent working relationships with all those involved in the provision and development of services for those with long-term conditions, sharing regular updates of planned care and any changes when they occur
• Work closely with the Frailty Team and others involved in care delivery to ensure patients have relevant referrals and access in place; attend and liaise with the Frailty Team MDT groups, regularly attending case conferences and providing relevant updates

• Communicate with patients in a welcoming way, which is non-judgmental and respects patients feelings, circumstances, and rights
• Utilise and demonstrate sensitive communication styles to ensure patients are fully informed of reasons for contact when contacting them for example, on welfare calls
• Communicate highly sensitive patient information and progress effectively with other team members and outside relevant health and social care providers, as appropriate
• Ensure all documented notes are contemporaneous

• Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance
• Participate in the management, review, and identification of learning from patient complaints and significant events
• Deliver evidence-based care according to the National Institute for Clinical Excellence (NICE) and Care Quality Commission (CQC) guidelines

• Possess basic computing and keyboard skills
• Have a good working knowledge of relevant areas of clinical systems and other programmes as appropriate to the role
• Demonstrate a good working knowledge of the policy on information and clinical governance

• Contribute to the collection of data for research/audit purposes
• Identify audit topics relevant to the Frailty Team

• Ensure all Statutory and Mandatory training is complete
• Avail of all opportunities to develop both clinical knowledge and practical skills

Essential

• Maths and English at minimum of GCSE or equivalent
• Up to date Statutory and Mandatory Training / be willing to undertake the training

Desirable

• Social Prescribing qualification

Essential

• Good communication skills
• Excellent organisational skills
• IT Literate

Desirable

• Evidence of cross boundary multi agency working

Essential

• Positive approach and smartly dressed
• Flexible working to cover colleagues as needed

Desirable

• Car driver

Essential

• Customer focused service delivery
• Team working
• Ability to deal with situations sensitively and appropriately, remaining polite and calm at all times

Desirable

• Experience in change management
• Evidence of management experience / training