Network Care Coordinator - Frailty Care Coordination MDT Pilot
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Network Care Coordinator - Frailty Care Coordination MDT Pilot
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Job Summary
The role will directly support the delivery of proactive care in the South-East Neighbourhood of Tower Hamlets supporting people with frailty needs who would benefit from coordinated care. This will be achieved by bringing together all the information about a person's identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.
Job Summary
The role will directly support the delivery of proactive care in the South-East Neighbourhood of Tower Hamlets supporting people with frailty needs who would benefit from coordinated care. This will be achieved by bringing together all the information about a person's identified care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person.
The job holder will organise and lead on monthly multi-disciplinary team meetings and have the opportunity to improve leadership skills, championing the proactive care model in the Neighbourhood and working with lead clinicians and professionals in the local authority and voluntary sectors.
The successful candidate will be based in either of the two Primary Care Networks in the South-East Neighbourhood. They will be caring, dedicated, reliable, person-focused and enjoy working with a wide range of people. They will have good written and verbal communication skills and strong organisational and time management skills. They will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing people, their families and carers with high quality support.
Main duties of the job
To work with our Network of practices to provide a central coordination role in patient care planning and delivery, putting in place a Personalised Care Support Plan, referring to health and social professionals as needed and to administer and lead monthly Multi- Disciplinary Team Meetings.
About Us
The Tower Hamlets South-East Neighbourhood is a partnership of 8 local general practices, community care teams, and local third-sector providers. It strives to deliver the best outcomes for its patients through a joined-up approach, quality access and equality of GP services. The successful candidates (x 2) will be joining a team of health professionals dedicated to provide integrated and patient-centred care, working on this 12 month Frailty Care Coordination MDT Pilot. If you are qualified, experienced and ready for a new challenge, why not join us!
Details
Date posted
08 August 2025
Pay scheme
Other
Salary
£28,000 to £34,000 a year includes high cost area supplements (HCAS)
Contract
Fixed term
Duration
12 months
Working pattern
Full-time
Reference number
A2175-25-080825
Job locations
21 Newby Place
London
E14 0EY
21 Newby Place
London
E14 0EY
Job Description
Job responsibilities
Key Responsibilities Of The Post
* Identify residents who would benefit from a Proactive Care approach
Coordinate the list of residents who fit the criteria of 65+, moderately frail, with COPD/CVD and are frequent hospital attendees and who could be supported by a Multidisciplinary Team (MDT) approach
Put in place for each resident who fits the criteria a Personalised Care and Support Plan, using EMIS
Cross-reference lists with relevant patient records (and other systems as appropriate) to gain an understanding of the different professionals involved in the care of the resident
Work with the relevant practitioners to prioritise the cohort list
Work closely with practitioners to develop an increased awareness of households and patients who may be vulnerable and in need of support
* Have discussions with residents focusing on what matters to them
Contact the resident to explain the proactive care offer and invite involvement
Carry out a holistic strengths-based assessment of need, and build trust
Communicate with the frailty and long-term conditions team with regards to health outcomes or any further assessment required
* Be a core part of Network Team MDTs
To act as a key member of the network MDT leading and supporting the development of effective meetings
Organise and lead monthly locality frailty care coordination MDT meetings
Attend Neighbourhood meeting as part of MDT i.e. frailty, COPD, CVD meetings
Bring for discussion patients identified for the proactive care pathway to the MDT
Work with practitioners to ensure that relevant professionals involved in the care and support of the individual are involved in MDT discussions where appropriate
* Coordinate support for the resident
Support people in managing their needs
Support people to take up training and employment, and to access appropriate benefits where eligible
Assist people in accessing self-management education courses, or interventions that enable them to support their health and wellbeing
Provide coordination and navigation for people and their carers across health and care services
Signpost residents to frailty, COPD and CVD and other relevant health services
Signpost and work with local authority team to support residents care needs and wider determinants of health (housing, blue badge, employment etc.)
* Good record keeping
Maintain accurate, confidential and up-to-date documentation on residents, including patients EMIS records
Keep MDT related information up to date (agenda, minutes, follow-up actions)
Ensure safeguarding arrangements are in place to support those residents identified for support
Maintain monitoring and reporting templates up to date
* Evaluate outcomes for individual residents
Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing using relevant goals-based measures
With the wider Neighbourhood, gather and collate information, evidence and anonymised stories, reporting on outcomes and activity. Ensure effective qualitative and quantitative monitoring and evaluation
* Leadership
Opportunity to champion the delivery of proactive care within the Neighbourhood, through a successful programme implementation
Opportunity to work closely with practices in coordinating residents if needed
Attend management meetings to update progress and concerns relating to the proactive care programme when required
* Working with others
Be an active member of the Neighbourhood team to build relationships with General Practice, adult community nursing, adult community therapies, mental health, adult social care and voluntary sector staff. Attend relevant service meetings, forums and contribute to continuous improvement of the Neighbourhood team
* Supervision and training
Proactively engage in training and support made available and undertake appropriate training with the Personalised Care Institute
Job Description
Job responsibilities
Key Responsibilities Of The Post
* Identify residents who would benefit from a Proactive Care approach
Coordinate the list of residents who fit the criteria of 65+, moderately frail, with COPD/CVD and are frequent hospital attendees and who could be supported by a Multidisciplinary Team (MDT) approach
Put in place for each resident who fits the criteria a Personalised Care and Support Plan, using EMIS
Cross-reference lists with relevant patient records (and other systems as appropriate) to gain an understanding of the different professionals involved in the care of the resident
Work with the relevant practitioners to prioritise the cohort list
Work closely with practitioners to develop an increased awareness of households and patients who may be vulnerable and in need of support
* Have discussions with residents focusing on what matters to them
Contact the resident to explain the proactive care offer and invite involvement
Carry out a holistic strengths-based assessment of need, and build trust
Communicate with the frailty and long-term conditions team with regards to health outcomes or any further assessment required
* Be a core part of Network Team MDTs
To act as a key member of the network MDT leading and supporting the development of effective meetings
Organise and lead monthly locality frailty care coordination MDT meetings
Attend Neighbourhood meeting as part of MDT i.e. frailty, COPD, CVD meetings
Bring for discussion patients identified for the proactive care pathway to the MDT
Work with practitioners to ensure that relevant professionals involved in the care and support of the individual are involved in MDT discussions where appropriate
* Coordinate support for the resident
Support people in managing their needs
Support people to take up training and employment, and to access appropriate benefits where eligible
Assist people in accessing self-management education courses, or interventions that enable them to support their health and wellbeing
Provide coordination and navigation for people and their carers across health and care services
Signpost residents to frailty, COPD and CVD and other relevant health services
Signpost and work with local authority team to support residents care needs and wider determinants of health (housing, blue badge, employment etc.)
* Good record keeping
Maintain accurate, confidential and up-to-date documentation on residents, including patients EMIS records
Keep MDT related information up to date (agenda, minutes, follow-up actions)
Ensure safeguarding arrangements are in place to support those residents identified for support
Maintain monitoring and reporting templates up to date
* Evaluate outcomes for individual residents
Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing using relevant goals-based measures
With the wider Neighbourhood, gather and collate information, evidence and anonymised stories, reporting on outcomes and activity. Ensure effective qualitative and quantitative monitoring and evaluation
* Leadership
Opportunity to champion the delivery of proactive care within the Neighbourhood, through a successful programme implementation
Opportunity to work closely with practices in coordinating residents if needed
Attend management meetings to update progress and concerns relating to the proactive care programme when required
* Working with others
Be an active member of the Neighbourhood team to build relationships with General Practice, adult community nursing, adult community therapies, mental health, adult social care and voluntary sector staff. Attend relevant service meetings, forums and contribute to continuous improvement of the Neighbourhood team
* Supervision and training
Proactively engage in training and support made available and undertake appropriate training with the Personalised Care Institute
Person Specification
Knowledge
Essential
* Understand the opportunities and challenges of working in a diverse, inner city area
* Commitment to reducing health inequalities and proactively working to reach people from all communities
* Understanding how integrated working supports residents in a holistic way
* Awareness of frailty, long-term conditions, poor health and the complexities involved physical, emotional and social
* Knowledge of how health and social care works including primary care
* Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety
Desirable
* Knowledge of PCNs, Neighbourhood, locality and the borough of Tower Hamlets
Qualifications
Essential
* Educated to GCSE level (or equivalent by experience).
* NVQ Level 4/5 or equivalent.
* Demonstrable commitment to professional and personal development
Experience
Essential
* Worked in statutory or voluntary sector services
* Worked in supportive roles that involved direct contact with the public, their families or carers (in a paid or voluntary capacity)
* Worked in multi team environments
* Been involved in or provided coordination support for MDTs
Desirable
* Worked in a Care Coordinator role or across adult health and social care or Public health improvement
Skills
Essential
* Able to communicate effectively, both verbally and in writing, with residents, their families, carers, community groups, partner agencies and stakeholders
* Ability to use EMIS, Microsoft Office applications Word, Excel, PowerPoint, Outlook
* Ability to collate and analyse data and use tools to measure impact
* An understanding of the importance of accurate and timely documentation, confidentiality, and safe information sharing
* Ability to listen, empathise with people and provide person- centred support in a non-judgmental way
* Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity
* Able to support people in a way that inspires trust, motivating others to reach their potential
* Commitment to collaborative working and the ability to maintain effective working relationships
* Personal accountability, emotional resilience and works well under pressure
* Ability to identify risk and assess/manage risk when working with individuals
* Ability to work flexibly and enthusiastically within a team or on own initiative
Desirable
* Proficient speaker of another language to aid communication with people in the community for whom English is a second language
* A strong awareness and understanding of when it is
* appropriate or necessary to refer people back to other health professionals/ agencies
Person Specification
Knowledge
Essential
* Able to communicate effectively, both verbally and in writing, with residents, their families, carers, community groups, partner agencies and stakeholders
* Ability to use EMIS, Microsoft Office applications Word, Excel, PowerPoint, Outlook
* Ability to collate and analyse data and use tools to measure impact
* An understanding of the importance of accurate and timely documentation, confidentiality, and safe information sharing
* Ability to listen, empathise with people and provide person- centred support in a non-judgmental way
* Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity
* Able to support people in a way that inspires trust, motivating others to reach their potential
* Commitment to collaborative working and the ability to maintain effective working relationships
* Personal accountability, emotional resilience and works well under pressure
* Ability to identify risk and assess/manage risk when working with individuals
* Ability to work flexibly and enthusiastically within a team or on own initiative
Desirable
* Proficient speaker of another language to aid communication with people in the community for whom English is a second language
* A strong awareness and understanding of when it is
* appropriate or necessary to refer people back to other health professionals/ agencies
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Employer details
Employer name
Poplar & Limehouse Health & Wellbeing Network PCN
Address
21 Newby Place
London
E14 0EY
Employer's website
http://www.poplarandlimehousehealthnetwork.com (Opens in a new tab)
Employer details
Employer name
Poplar & Limehouse Health & Wellbeing Network PCN
Address
21 Newby Place
London
E14 0EY
Employer's website
http://www.poplarandlimehousehealthnetwork.com (Opens in a new tab)
LNKD1_UKTJ
Seniority level
* Seniority level
Mid-Senior level
Employment type
* Employment type
Contract
Job function
* Job function
Other
* Industries
IT Services and IT Consulting
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