Frailty care coordinator

What they do

A frailty care coordinator is a key member of the primary care team who provides dedicated support for patients living with frailty. This non-clinical role focuses on providing holistic and person-centred care to help patients manage their health and well-being, enabling them to live independently for as long as possible. They work proactively with individuals who are elderly, frail, or have long-term conditions, helping them and their carers to navigate the complexities of health and social care services.

Frailty care coordinators work in close collaboration with GPs, frailty nurses, social prescribing link workers, and other healthcare professionals to ensure patients receive seamless and joined-up care tailored to their specific needs. Their role involves coordinating appointments, creating personalised care plans, and acting as a central point of contact for patients and their families.

Key aims

• Act as a main point of contact for patients and their carers, offering guidance and support to navigate health and care services.
• Develop and review personalised care plans that reflect the patient’s individual needs and wishes.
• Empower patients to better understand and manage their health conditions, thereby increasing their confidence and independence.
• Connect patients with relevant local support services and resources, such as befriending services or fitness programs, to enhance their wellbeing.
• Proactively identify and support patients at risk, particularly after a hospital discharge or during a decline in health, to ensure they receive timely follow-up care.
• Contribute to the reduction of avoidable hospital admissions by providing intensive case management and support in the community.

How to connect with them

If you think you or someone you care for could benefit from the support of a frailty care coordinator, you can contact your GP surgery’s reception team and ask for an appointment. In some cases, the frailty care coordinator may contact patients directly after identifying them through clinical system searches. Appointments can be arranged in person, either at the surgery or at your home, or over the telephone.

Our team members

• Benita McMinn