Job summary
An exciting opportunity has arisen for anexperienced practitioner to lead the Integrated Care service and Social Prescribing Link Worker (SPLW) outputs within DrylandSurgery. You will be the key decision-maker for the people whose care you aresupporting, operating as a go-to person for the practice to ensure that theircollaborative care is timely and seamless, and that everyone involved isworking together. Your support will enable health and wellbeing, support behaviour changeto achieve a healthy lifestyle, and address health inequalities.
You will work closely with the GPs and otherprimary care professionals within the practice and the wider NHS - includingcommunity groups, Adult Social Care and Age UK - to identify and manage acaseload of identified patients - that includes young people and frail, elderlyservice users - making sure that appropriate support is made available to themand their carers, and ensuring that their changing needs are addressed.
Main duties of the job
As an autonomous practitioner, you'll work with and supportindividuals to identify their needs, develop personalised care and supportplans, build up their resilience, and increase their active involvement withtheir local communities. As a socialprescriber, you'll review plans with your service users at regular intervalsto capture progress, ensure they remain appropriate for the individual.
You will workcollaboratively with local partners and communities to identify local communityassets (Voluntary, Community and Social Enterprise (VCSE) organisations).
The successful candidate will also:
Take overall responsibility for coordination anddelivery of the Frailty MDT meetings, ensuring that all new referrals areidentified.
Utilise population health intelligence to deliver personalisedcare.
Support patients ina Shared Decision-Making conversation.
Holistically bring together all of a personsidentified care and support needs, and explore options to meet these within asingle personalised care and support plan (PCSP), in line with bestpractice, based on what matters to the person.
Help people make choices about theircare.
Forge strong links with a widerange of local VCSE organisations, community and neighbourhood level groups, creating amenu of diverse community groups and assets, who promote diversity andinclusion.
About us
Primary Care Teams are growing and evolving and nowseeking more staff to deliver the care services to our patients. You would leada 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 at enhancingpatient services in the local community.
Vibrant, friendly working atmosphere with greatopportunities
Our ethos includes:
Supporting patients to utilise decision aids in preparation for ashared decision-making conversation.
Holistically bringing together all of a persons identified care andsupport needs, and exploring options to meet these within a single personalisedcare and support plan (PCSP), in line with PCSP best practice, based on whatmatters to the person.
Helping people to manage their needs through answering queries, makingand managing appointments, and ensuring that people have good quality writtenor verbal information to help them make choices about their care.
Supporting people to take up training and employment, and to accessappropriate benefits where eligible.
Supporting people to understand their level of knowledge, skillsand confidence when engaging with their health and wellbeing.
Job description
Job responsibilities
Take overall responsibility for coordination and delivery of the MDTmeetings.
A key role of the Care Coordinator will be to schedule the MDT meetings,manage the meeting agenda items; ensuring that all new referrals areidentified, and information circulated to team members in advance of themeeting. Utilise population health intelligence and PCN / Partner data toproactively identify and work with a cohort of patients to deliver personalisedcare.
Support patients to utilise decision aids in preparation for a shareddecision-making conversation.
Holistically bring together all of a persons identified care and supportneeds, and explore options to meet these within a single personalised care andsupport plan (PCSP), in line with PCSP best practice, based on what matters tothe person.
Help people to manage their needs through answering queries, making andmanaging appointments, and ensuring that people have good quality written orverbal information to help them make choices about their care.
Support people to take up training and employment, and to accessappropriate benefits where eligible.
Support people to understand their level of knowledge, skills andconfidence when engaging with their health and wellbeing.
Assist people to access self-management education courses, peer supportor interventions that support them in their health and wellbeing and increasetheir activation level.
Explore and assist people to access personal health budgets whereappropriate.
Provide coordination and navigation for people and their carers acrosshealth and care services, working closely with social prescribing link workers,health and wellbeing coaches, and other primary care professionals.
Work with the GPs and other primary care professionals within the practiceto identify and manage a caseload of patients, and where required and asappropriate, refer people back to other health professionals.
Raise awareness of how to identify patients who may benefit from shareddecision making and support staff and patients to be more prepared to haveshared decision-making conversations.
Person Specification
Qualifications
Essential
1. Professional clinical qualifications or competencies commensurate to a Band 7 AfC appointment.
2. GCSE or equivalent grade C level qualification in Maths and English.
3. Experience Minimum of one years' experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field.
4. Experience of coordinating and liaising with multiple stakeholders or individuals to meet specified outcomes.
5. Experience providing advice/signposting to patients.
6. Experience of undertaking quality improvement activity.
7. Excellent organisational and administration skills.
8. Ability to analyse and interpret information and present results in a clear and concise manner.
9. Able to prioritise and manage own workload.
Desirable
10. Experience of working in a multi-disciplinary setting where influence and negotiation is required.
11. Experience of using technology and digital tools to support health and wellbeing.
12. Experience of co-production with patients or service-users.
13. Skills and Knowledge Excellent influencing and negotiating skills.
Experience
Essential
14. Experience working within a healthcare setting and interacting with patients.
15. Ability to manage own outputs and wider MDT's workload.
16. Recognition of priorities and sound time/resource management
17. Excellent influencing and negotiating skills.