Kettering & South West Rural Primary Care Network
An exciting opportunity has arisen for an experienced practitioner to lead the Integrated Care service and Social Prescribing Link Worker (SPLW) outputs within Dryland Surgery. You will be the key decision-maker for the people whose care you are supporting, operating as a go-to person for the practice to ensure that their collaborative care is timely and seamless, and that everyone involved is working together. Your support will enable health and wellbeing, support behaviour change to achieve a healthy lifestyle, and address health inequalities.
You will work closely with the GPs and other primary care professionals within the practice and the wider NHS - including community groups, Adult Social Care and Age UK - to identify and manage a caseload of identified patients that includes young people and frail, elderly service users, ensuring that appropriate support is made available to them and their carers, and that their changing needs are addressed.
Main duties of the job
As an autonomous practitioner, you'll work with and support individuals to identify their needs, develop personalised care and support plans, build up their resilience, and increase their active involvement with their local communities. As a social prescriber, you'll review plans with your service users at regular intervals to capture progress, ensuring they remain appropriate for the individual.
You will work collaboratively with local partners and communities to identify local community assets (Voluntary, Community and Social Enterprise (VCSE) organisations).
The successful candidate will also:
1. Take overall responsibility for coordination and delivery of the Frailty MDT meetings, ensuring that all new referrals are identified.
2. Utilise population health intelligence to deliver personalised care.
3. Support patients in a Shared Decision-Making conversation.
4. Holistically bring together all of a person's identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with best practice, based on what matters to the person.
5. Help people make choices about their care.
6. Forge strong links with a wide range of local VCSE organisations, community and neighbourhood level groups, creating a menu of diverse community groups and assets, who promote diversity and inclusion.
About us
Primary Care Teams are growing and evolving and now seeking more staff to deliver the care services to our patients. You would lead a Multi-Disciplinary Team (MDT) at Dryland Surgery comprising of colleagues from general practice, Adult Social Care and Age UK to support GPs and clinical teams in enhancing patient services in the local community.
Vibrant, friendly working atmosphere with great opportunities.
Job responsibilities
1. Take overall responsibility for coordination and delivery of the MDT meetings.
2. A key role of the Care Coordinator will be to schedule the MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members in advance of the meeting.
3. Utilise population health intelligence and PCN / Partner data to proactively identify and work with a cohort of patients to deliver personalised care.
4. Support patients to utilise decision aids in preparation for a shared decision-making conversation.
5. Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care.
6. Support people to take up training and employment, and to access appropriate benefits where eligible.
7. Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing.
8. Assist people to access self-management education courses, peer support, or interventions that support them in their health and wellbeing and increase their activation level.
9. Explore and assist people to access personal health budgets where appropriate.
10. Provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals.
11. Work with the GPs and other primary care professionals within the practice to identify and manage a caseload of patients, and where required and as appropriate, refer people back to other health professionals.
12. Raise awareness of how to identify patients who may benefit from shared decision making and support staff and patients to be more prepared to have shared decision-making conversations.
Person Specification
Qualifications
* Professional clinical qualifications or competencies commensurate to a Band 7 AfC appointment.
* GCSE or equivalent grade C level qualification in Maths and English.
* Minimum of one year's experience of working with healthcare professionals and/or previous experience in the NHS or social care or relevant field.
* Experience of coordinating and liaising with multiple stakeholders or individuals to meet specified outcomes.
* Experience providing advice/signposting to patients.
* Experience of undertaking quality improvement activity.
* Excellent organisational and administration skills.
* Ability to analyse and interpret information and present results in a clear and concise manner.
* Able to prioritise and manage own workload.
* Experience of working in a multi-disciplinary setting where influence and negotiation is required.
* Experience of using technology and digital tools to support health and wellbeing.
* Experience of co-production with patients or service-users.
Experience
* Experience working within a healthcare setting and interacting with patients.
* Ability to manage own outputs and wider MDT's workload.
* Recognition of priorities and sound time/resource management.
* Excellent influencing and negotiating skills.
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 name
Kettering & South West Rural Primary Care Network
Depending on experience Salary negotiable
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