Neighbourhood Frailty Care Coordinator

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Heartbeat Primary Care CIC Neighbourhood Frailty Care Coordinator

The closing date is 25 November 2026

Apply for this job

Job summary

Help us shape the future of neighbourhood care

Are you organised, proactive and passionate about bringing people and services together to improve care?

Heartbeat Primary Care CIC is looking for two Neighbourhood Frailty Care Coordinator's to play a key role in the development and delivery of our Proactive Frailty Model. We are recruiting for separate positions: one covering Hambleton and one covering Richmondshire, each focused on supporting patients and services within their local area.

This is an exciting opportunity to support a developing approach to integrated neighbourhood care, helping primary care, community health, social care, mental health and voluntary sector organisations work together to provide more coordinated, personalised support for people living with frailty.

About the role

This is a non-clinical role, offering an opportunity to help shape a developing service.

You will be central to coordinating our neighbourhood multidisciplinary teams (MDTs), bringing professionals together to identify people's needs, agree actions and ensure support is coordinated and followed through.

Working closely with practices and partner organisations, you will help strengthen communication, support proactive identification of people who may benefit from additional care and contribute to developing effective ways of working across our neighbourhoods.

Main duties of the job

Key responsibilities include:

• Coordinating and facilitating neighbourhood MDT meetings.
• Supporting proactive identification and prioritisation of people living with frailty.
• Coordinating agreed actions, care planning and follow-up across services.
• Building effective relationships with health, social care and community partners.
• Supporting patient tracking, activity monitoring and service improvement.

About us

Heartbeat Primary Care CIC is the GP Federation for Hambleton and Richmondshire a Community Interest Company (CIC) owned by the GP Practices in the area. We aim to meet everyday health and care needs by supporting the communities we serve with innovative quality services. Our mission is underpinned by our values: Being Professional taking ownership and pride in the delivery of high quality services. Being trusted we are open, transparent and deliver on our promises. Being Supportive we care about patients and each other.

We provide at scale clinical services across our neighbourhoods and core GP services from Harewood Medical Practice in Catterick Garrison.

Heartbeat is an ambitious and forward-thinking GP Federation evolving into a Multi-Neighbourhood Provider (MNP). This proposed collaborative model unites primary care, community services, local authorities, social care, and the voluntary sector to deliver integrated, population-based care that enhances outcomes, addresses inequalities, and builds resilient local health systems.

Details

Date posted

27 October 2026

Pay scheme

Other

Salary

£30,562 a year FTE

Contract

Permanent

Working pattern

Full-time

Reference number

C0003-26-0005

Job locations

Evolution Business Centre

Darlington Road

Northallerton

DL6 2NQ

United Kingdom

Job description

Job responsibilities

The Neighbourhood Frailty Care Coordinator plays a pivotal role in the delivery of the Hambleton and Richmondshire Proactive Frailty Model, providing operational coordination across neighbourhood multidisciplinary teams (MDTs).

Working in partnership with General Practice, Community Services, Adult Social Care, Mental Health, Medicines Optimisation, VCSE organisations and other system partners, the post holder will coordinate Neighbourhood MDTs, support proactive population health management and facilitate integrated care planning and delivery.

The role is non-clinical and focuses on operational and service coordination, Individual patient pathway integration, quality improvement and performance monitoring to improve outcomes for people living with frailty and support the delivery of integrated neighbourhood care.

MAIN DUTIES AND RESPONSIBILITIES

Facilitation

The post holder will:

• Facilitate and, where necessary, chair Neighbourhood MDT meetings in partnership with the clinical lead/practice clinicians, ensuring discussions remain focused on proactive care planning, coordinated actions and agreed patient outcomes.
• Coordinate all aspects of the MDT process, including meeting planning, patient identification, agendas, supporting documentation, meeting logistics and follow-up activity, enabling clinical leads to focus on clinical decision-making.
• Gather and present relevant patient information and coordinate appropriate professional representation to support informed multidisciplinary discussion and collaborative decision-making.
• Ensure discussions always keep the patient at the centre of consideration, taking account of their needs, wishes and circumstances.
• Facilitate inclusive and outcome-focused MDT discussions, ensuring decisions, actions, responsibilities and timescales are clearly recorded, communicated and monitored through to completion.
• Act as the operational coordinator and first point of contact for GP practices and partner organisations in relation to Neighbourhood MDT processes, providing advice and support to promote effective and consistent delivery.
• Maintain robust processes for the secure receipt, management and sharing of patient information in accordance with Information Governance, Data Protection and organisational requirements.
• Remain mindful of allotted time by encouraging concise, focussed discussion to ensure meetings are effective.

Population Health Management

The post holder will:

• Utilise agreed population health management tools, clinical systems and reporting dashboards to support proactive case finding and identify individuals who may benefit from multidisciplinary review or early intervention.
• Analyse agreed frailty and deterioration indicators, including hospital admissions, Emergency Department attendances, falls and other locally agreed triggers, to support identification and prioritisation of individuals at increased risk.
• Develop, maintain and regularly review neighbourhood frailty cohorts, patient tracking systems and frailty registers, supporting General Practice to maintain accurate coding, recording and data quality.
• Coordinate the identification and prioritisation of patients for Neighbourhood MDT discussion, ensuring those with the greatest complexity, risk or unmet need are reviewed in a timely manner.
• Maintain operational oversight of the neighbourhood frailty caseload, working with General Practice and system partners to coordinate multidisciplinary assessment, personalised care planning, pathway progression and escalation to the Integrated Neighbourhood Team (INT) where appropriate.

Care Coordination

The post holder will:

• Coordinate the implementation of agreed actions arising from Neighbourhood MDT discussions, ensuring responsibilities are clearly communicated, progressed within agreed timescales and reviewed through subsequent MDT meetings where appropriate.
• Work collaboratively with General Practice, Community Services, Adult Social Care, Mental Health, Medicines Optimisation, VCSE organisations and other partner agencies to coordinate timely referrals, assessments, actions and ongoing service involvement, ensuring patients receive seamless, coordinated care.
• Maintain operational oversight of patients progressing through the Neighbourhood Frailty Model, ensuring agreed actions are implemented, monitored and reviewed, and supporting timely escalation to the Integrated Neighbourhood Team (INT) or other appropriate services where required.
• Act as an accessible point of contact for patients and carers where appropriate, providing information, facilitating communication between organisations and supporting engagement with agreed care plans, services and actions.
• Promote effective communication and information sharing between professionals, working collaboratively to resolve barriers, support continuity of care and reduce unnecessary duplication.

Service Improvement, Performance and Evaluation

The post holder will:

• Identify opportunities to improve operational processes, MDT effectiveness and patient outcomes, working with practices and partner organisations to develop and implement practical solutions.
• Support the development, implementation and review of standard operating procedures, operational guidance, pathways and agreed ways of working across the Proactive Frailty Model.
• Promote consistency and continuous improvement across neighbourhoods by sharing learning, good practice and supporting the adoption of new ways of working.
• Develop and maintain, with appropriate support, neighbourhood frailty dashboards, KPI tracking systems, patient tracking systems and operational performance information to meet agreed reporting requirements.
• Monitor and report on MDT activity, patient pathways, outcomes and agreed performance measures, supporting audit, evaluation and quality improvement through the collection and analysis of operational data.
• Identify and escalate emerging risks, variation, data quality or performance concerns through appropriate governance arrangements and support agreed improvement actions.

Relationships and Communication

The post holder will be expected to:

• Build and maintain effective working relationships with General Practice, Community Services, Adult Social Care, Mental Health, Medicines Optimisation, VCSE organisations, Secondary Care and other partner agencies to support integrated neighbourhood working.
• Act as the key operational link between partner organisations, facilitating effective communication, information sharing and collaborative problem-solving to support coordinated, person-centred care.
• Promote partnership working and joint decision-making, ensuring effective communication between organisations and supporting continuity of care across the neighbourhood pathway.
• Develop positive relationships with patients and carers, ensuring they remain at the centre of care planning and service delivery where appropriate.
• Represent the Neighbourhood Frailty Model positively across partner organisations, promoting engagement, consistency, innovation and continuous improvement.

Job description

Job responsibilities

The Neighbourhood Frailty Care Coordinator plays a pivotal role in the delivery of the Hambleton and Richmondshire Proactive Frailty Model, providing operational coordination across neighbourhood multidisciplinary teams (MDTs).

Working in partnership with General Practice, Community Services, Adult Social Care, Mental Health, Medicines Optimisation, VCSE organisations and other system partners, the post holder will coordinate Neighbourhood MDTs, support proactive population health management and facilitate integrated care planning and delivery.

The role is non-clinical and focuses on operational and service coordination, Individual patient pathway integration, quality improvement and performance monitoring to improve outcomes for people living with frailty and support the delivery of integrated neighbourhood care.

MAIN DUTIES AND RESPONSIBILITIES

Facilitation

The post holder will:

• Facilitate and, where necessary, chair Neighbourhood MDT meetings in partnership with the clinical lead/practice clinicians, ensuring discussions remain focused on proactive care planning, coordinated actions and agreed patient outcomes.
• Coordinate all aspects of the MDT process, including meeting planning, patient identification, agendas, supporting documentation, meeting logistics and follow-up activity, enabling clinical leads to focus on clinical decision-making.
• Gather and present relevant patient information and coordinate appropriate professional representation to support informed multidisciplinary discussion and collaborative decision-making.
• Ensure discussions always keep the patient at the centre of consideration, taking account of their needs, wishes and circumstances.
• Facilitate inclusive and outcome-focused MDT discussions, ensuring decisions, actions, responsibilities and timescales are clearly recorded, communicated and monitored through to completion.
• Act as the operational coordinator and first point of contact for GP practices and partner organisations in relation to Neighbourhood MDT processes, providing advice and support to promote effective and consistent delivery.
• Maintain robust processes for the secure receipt, management and sharing of patient information in accordance with Information Governance, Data Protection and organisational requirements.
• Remain mindful of allotted time by encouraging concise, focussed discussion to ensure meetings are effective.

Population Health Management

The post holder will:

• Utilise agreed population health management tools, clinical systems and reporting dashboards to support proactive case finding and identify individuals who may benefit from multidisciplinary review or early intervention.
• Analyse agreed frailty and deterioration indicators, including hospital admissions, Emergency Department attendances, falls and other locally agreed triggers, to support identification and prioritisation of individuals at increased risk.
• Develop, maintain and regularly review neighbourhood frailty cohorts, patient tracking systems and frailty registers, supporting General Practice to maintain accurate coding, recording and data quality.
• Coordinate the identification and prioritisation of patients for Neighbourhood MDT discussion, ensuring those with the greatest complexity, risk or unmet need are reviewed in a timely manner.
• Maintain operational oversight of the neighbourhood frailty caseload, working with General Practice and system partners to coordinate multidisciplinary assessment, personalised care planning, pathway progression and escalation to the Integrated Neighbourhood Team (INT) where appropriate.

Care Coordination

The post holder will:

• Coordinate the implementation of agreed actions arising from Neighbourhood MDT discussions, ensuring responsibilities are clearly communicated, progressed within agreed timescales and reviewed through subsequent MDT meetings where appropriate.
• Work collaboratively with General Practice, Community Services, Adult Social Care, Mental Health, Medicines Optimisation, VCSE organisations and other partner agencies to coordinate timely referrals, assessments, actions and ongoing service involvement, ensuring patients receive seamless, coordinated care.
• Maintain operational oversight of patients progressing through the Neighbourhood Frailty Model, ensuring agreed actions are implemented, monitored and reviewed, and supporting timely escalation to the Integrated Neighbourhood Team (INT) or other appropriate services where required.
• Act as an accessible point of contact for patients and carers where appropriate, providing information, facilitating communication between organisations and supporting engagement with agreed care plans, services and actions.
• Promote effective communication and information sharing between professionals, working collaboratively to resolve barriers, support continuity of care and reduce unnecessary duplication.

Service Improvement, Performance and Evaluation

The post holder will:

• Identify opportunities to improve operational processes, MDT effectiveness and patient outcomes, working with practices and partner organisations to develop and implement practical solutions.
• Support the development, implementation and review of standard operating procedures, operational guidance, pathways and agreed ways of working across the Proactive Frailty Model.
• Promote consistency and continuous improvement across neighbourhoods by sharing learning, good practice and supporting the adoption of new ways of working.
• Develop and maintain, with appropriate support, neighbourhood frailty dashboards, KPI tracking systems, patient tracking systems and operational performance information to meet agreed reporting requirements.
• Monitor and report on MDT activity, patient pathways, outcomes and agreed performance measures, supporting audit, evaluation and quality improvement through the collection and analysis of operational data.
• Identify and escalate emerging risks, variation, data quality or performance concerns through appropriate governance arrangements and support agreed improvement actions.

Relationships and Communication

The post holder will be expected to:

• Build and maintain effective working relationships with General Practice, Community Services, Adult Social Care, Mental Health, Medicines Optimisation, VCSE organisations, Secondary Care and other partner agencies to support integrated neighbourhood working.
• Act as the key operational link between partner organisations, facilitating effective communication, information sharing and collaborative problem-solving to support coordinated, person-centred care.
• Promote partnership working and joint decision-making, ensuring effective communication between organisations and supporting continuity of care across the neighbourhood pathway.
• Develop positive relationships with patients and carers, ensuring they remain at the centre of care planning and service delivery where appropriate.
• Represent the Neighbourhood Frailty Model positively across partner organisations, promoting engagement, consistency, innovation and continuous improvement.

Person Specification

Experience

Essential

• Working within a health, social care or wider public sector environment.
• Coordinating multidisciplinary or multi-agency working across organisational boundaries.
• Planning, organising, facilitating and supporting meetings involving multiple stakeholders.
• Managing competing priorities and delivering work within agreed timescales.
• Building effective working relationships across organisations to achieve shared outcomes.
• Maintaining accurate records, handling confidential information and producing operational reports.
• Using operational data and information to support planning, service delivery and decision-making.

Desirable

• Experience of working within Primary Care, including General Practice, Primary Care Networks or GP Federations.
• Supporting frailty, ageing well, long-term conditions or older people's services.
• Working with Population Health Management approaches, proactive case finding or Neighbourhood MDTs.
• Contributing to service improvement, transformation, pathway redesign or quality improvement initiatives.
• Supporting integrated neighbourhood or community-based models of care.

Knowledge and Skills

Essential

• Excellent written, verbal and interpersonal communication skills.
• Excellent organisational and planning skills, with the ability to manage competing priorities.
• Ability to build productive working relationships across a broad range of stakeholders and work effectively within multidisciplinary teams.
• Ability to facilitate meetings, coordinate operational activity and support collaborative decision-making.
• Confident in leading discussions and summarising key points to ensure actions and decisions are identified.
• Competent in Microsoft Office applications, including Outlook, Word, Excel and Teams.
• Understanding of confidentiality, Information Governance, Data Protection and the secure handling of sensitive information.

Desirable

• Knowledge of SystmOne or other NHS clinical systems.
• Knowledge of Population Health Management approaches and proactive case finding.
• Understanding of frailty, ageing well and integrated neighbourhood working.
• Knowledge of the wider NHS and health and care system.

Personal Attributes

Essential

• Professional, approachable, tactful and diplomatic, with the ability to build credibility and trust with a wide range of stakeholders.
• Flexible, adaptable and able to respond positively to changing priorities.
• Self-motivated, enthusiastic and able to work independently using own initiative.
• A collaborative team player who values partnership working and shared decision-making.
• Excellent attention to detail and a commitment to delivering high-quality work.
• Committed to delivering person-centred care and improving outcomes for people living with frailty.
• Demonstrates resilience and remains calm under pressure.
• Ability to engage with a diverse range of professionals.
• Committed to continuous learning, innovation and service improvement.
• Ability to travel independently across Hambleton and Richmondshire to meet the operational requirements of the role.

Desirable

• Full UK driving licence and access to a vehicle for business use.
• Positive ambassador for integrated neighbourhood working and collaborative care.

Person Specification

Experience

Essential

• Working within a health, social care or wider public sector environment.
• Coordinating multidisciplinary or multi-agency working across organisational boundaries.
• Planning, organising, facilitating and supporting meetings involving multiple stakeholders.
• Managing competing priorities and delivering work within agreed timescales.
• Building effective working relationships across organisations to achieve shared outcomes.
• Maintaining accurate records, handling confidential information and producing operational reports.
• Using operational data and information to support planning, service delivery and decision-making.

Desirable

• Experience of working within Primary Care, including General Practice, Primary Care Networks or GP Federations.
• Supporting frailty, ageing well, long-term conditions or older people's services.
• Working with Population Health Management approaches, proactive case finding or Neighbourhood MDTs.
• Contributing to service improvement, transformation, pathway redesign or quality improvement initiatives.
• Supporting integrated neighbourhood or community-based models of care.

Knowledge and Skills

Essential

• Excellent written, verbal and interpersonal communication skills.
• Excellent organisational and planning skills, with the ability to manage competing priorities.
• Ability to build productive working relationships across a broad range of stakeholders and work effectively within multidisciplinary teams.
• Ability to facilitate meetings, coordinate operational activity and support collaborative decision-making.
• Confident in leading discussions and summarising key points to ensure actions and decisions are identified.
• Competent in Microsoft Office applications, including Outlook, Word, Excel and Teams.
• Understanding of confidentiality, Information Governance, Data Protection and the secure handling of sensitive information.

Desirable

• Knowledge of SystmOne or other NHS clinical systems.
• Knowledge of Population Health Management approaches and proactive case finding.
• Understanding of frailty, ageing well and integrated neighbourhood working.
• Knowledge of the wider NHS and health and care system.

Personal Attributes

Essential

• Professional, approachable, tactful and diplomatic, with the ability to build credibility and trust with a wide range of stakeholders.
• Flexible, adaptable and able to respond positively to changing priorities.
• Self-motivated, enthusiastic and able to work independently using own initiative.
• A collaborative team player who values partnership working and shared decision-making.
• Excellent attention to detail and a commitment to delivering high-quality work.
• Committed to delivering person-centred care and improving outcomes for people living with frailty.
• Demonstrates resilience and remains calm under pressure.
• Ability to engage with a diverse range of professionals.
• Committed to continuous learning, innovation and service improvement.
• Ability to travel independently across Hambleton and Richmondshire to meet the operational requirements of the role.

Desirable

• Full UK driving licence and access to a vehicle for business use.
• Positive ambassador for integrated neighbourhood working and collaborative care.

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

Heartbeat Primary Care CIC

Address

Evolution Business Centre

Darlington Road

Northallerton

DL6 2NQ

United Kingdom

Employer's website

https://www.heartbeatprimarycare.org/ (Opens in a new tab)

Employer details

Employer name

Heartbeat Primary Care CIC

Address

Evolution Business Centre

Darlington Road

Northallerton

DL6 2NQ

United Kingdom

Employer's website

https://www.heartbeatprimarycare.org/ (Opens in a new tab)

Employer contact details

For questions about the job, contact:

Neighbourhood Delivery Manager

Zoe Battersby

[email protected]

Details

Date posted

27 October 2026

Pay scheme

Other

Salary

£30,562 a year FTE

Contract

Permanent

Working pattern

Full-time

Reference number

C0003-26-0005

Job locations

Evolution Business Centre

Darlington Road

Northallerton

DL6 2NQ

United Kingdom

Supporting links (all open in new tabs)

Heartbeat Primary Care Website

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