Title: Proactive Care Practitioner
Reports to: Clinical Services Manager
Responsible to: Surrey Heath Primary Care Network (SH PCN) and Surrey Heath Community Providers Ltd (SHCPL, ‘The Federation’)
Base: Surrey Heath Community Providers Ltd, Theta building, Frimley Rd, Frimley, Camberley GU16 7ER. The role will require working across the practices within the Federation / Surrey Heath Primary Care Network (PCN) footprint and patients’ residential settings across the footprint.
Hours per week: 37.5 (Full time), Part Time considered. Core hours will be Monday to Friday, between 09:00 – 17:00, but you may be required to work evenings or weekends depending on the needs of the business and the patient cohort.
Salary: Band 6 (starting at £35,391) or Band 7 (starting at £43,742), depending on experience and qualifications.
Holiday Entitlement: From 27 days per year (based on full time hours), dependent on length of NHS service, plus Bank Holiday entitlement.
Key Relationships: Clinical Services Manager, Clinical Team Leader, Surrey Heath Integrated Care Team, Frailty administration support, Associate Director of Operations, PCN Directors, Practice Managers within Surrey Heath Federation, GPs within Surrey Heath Federation, Provider organisations.
ABOUT US:
We are Surrey Heath Community Providers Limited, which is a federation of 7 GP practices across 10 sites, covering a population of over 103,000 patients across Surrey Heath. We began in 2016 and now employ around 200 members of staff across our head office sites, and our primary care and unplanned care services.
As a GP Federation, we are proud to represent our member practices and to champion primary care by working with local general practice and system partners in the provision of community-based healthcare services. We are dedicated to providing safe and compassionate care to our patients across our range of primary care and unplanned healthcare services in Surrey Heath, and believe in continuous commitment to quality service delivery and positive patient outcomes.
Patients are at the heart of everything we do, and we pride ourselves in ensuring our patients feel safe, supported, communicated with and respected, at a time when they may be feeling vulnerable. Our vision is to provide high quality, seamless health care that enables people to lead healthier lives, whilst feeling supported and cared for.
ROLE SUMMARY:
The Proactive Care Practitioner will provide a responsive, safe, effective caring ‘Proactive Care’ service. The service aims to support an identified cohorts of people living with mild to moderate frailty and long term conditions, providing comprehensive assessment and proactive case management.
This will include adopting a shared decision making approach and supporting self-management through sign-posting, health coaching and social prescribing, MDT discussion and onward referral as required.
The Proactive Care service, whilst operating from a local hub, will require travel to Practices or patients homes across the Surrey Heath PCN geography.
KEY RESPONSIBILITIES AND DUTIES:
* To work closely with the Integrated Care Team, Frailty MDT and local GP teams to provide proactive care services for patients with frailty or those with a long term condition identified as requiring an anticipatory approach.
* To support the identification of the target cohort for whom there is the greatest potential impact on health and system outcomes.
* To provide specialist assessment of patients, using analytical and judgment skills. To provide appropriate patient centred treatment using evidence based practice where-ever possible. Patients will present with acute or chronic conditions and complex multi-system pathologies e.g. neuro, respiratory conditions, orthopaedic rehabilitation and age related deterioration.
* To ensure holistic assessment using an agreed approach, such as comprehensive geriatric assessment (CGA).
* To devise effective personalised care plans for each patient with specific therapeutic knowledge, recognising him or her as an individual. The plan of care, which has been developed in conjunction with the patient, carer and relevant others, should be outcome based and ensure appropriate pathways of care and communication via liaison and referral to other agencies as required.
* The goals and objectives of any intervention are clearly established and negotiated, and where appropriate can be assessed through use of outcome measures/ objective markers.
* To provide an holistic and therapeutic treatment programme or where appropriate direct the intervention as necessary through other members of the multi-disciplinary team.
* To provide advice, guidance, sign-posting, treatment and care planning where appropriate, developing a personalised care plan.
* To support the delivery of co-ordinated multi-professional interventions to address the person’s range of needs.
* To work closely with appropriate others to proactively identify and manage patients with frailty and support them and their carers in the development and delivery of anticipatory care.
* To work in conjunction with a wide range of colleagues and specifically, primary care and community teams and Social Care professionals, leading and facilitating a patient or client focused, co-ordinated case management approach across primary and secondary care for people who are most vulnerable to, and at high risk of repeat admissions to hospital, and those who would benefit from an anticipatory approach.
* To participate in and influence efforts across health and social services to shape multi-disciplinary pathways designed to support patient choice, improve quality of life, promote self-management and assure early intervention through the proactive provision of care in or as close to the patient’s own home as possible.
* To work across the caseload for Surrey Heath, using their clinical skills to identify the needs of patients and the correct services to liaise with.
* To provide expertise in their own discipline to the wider team.
* To advise on the promotion of health and prevention of illness and provide information to individuals and groups to prevent disease, where possible. Recognise situations that may be detrimental to health for example housing, social and economic factors and refer to an appropriate agency and liaise with members of the Community Teams
* To provide complex case management using extended skills where appropriately trained to reduce the dependence on statutory services and support avoidance of hospital admission and manage clinical needs in the community setting
* To provide comprehensive line management to nominated team members.
ADDITIONAL RESPONSIBILITIES:
* Act at all times with compassion, and be committed to delivering high quality care, using effective communication, clinical competence and courage when needed.
* Review effectiveness of clinical care provided ensuring that patient safety is maintained and care delivery meets the standards required by the PCN and the Care Quality Commission.
* Monitor the quality of care planning, implementation and evaluation to ensure optimum quality is maintained.
* Maintain uphold and follow the standards within the practitioner’s regulatory body code of conduct at all times ensure safe and effective delivery of patient care.
* Inform your line manager of any concerns with patients, relatives, visitors or staff that may compromise patient care.
* Develop and maintain constructive working relationships and liaise effectively with all members of the multidisciplinary team so that patients’ needs are met.
* Communicate effectively with colleagues, patients and carers so that information is shared in order to meet patients’ needs.
* Act as a role model in the promotion of person-centred practice, and challenge practice which is not person-centred, so that a person-centred culture is maintained.
* Keep updated with relevant clinical developments and use knowledge to enhance standards of care.
* Practice, role model and promote safe and effective skills in all aspects of clinical practice.
* Encourage a culture of patient wellness and coproduction using a health coaching approach.
* Demonstrate, care, compassion, competence, effective communication, courage and commitment with all patients and carers.
* Recognise own limitations in the provision of clinical care and urgency of patient’s needs, referring to other professionals accordingly and is accountable for his/her own action.
* All our Registered healthcare professionals may be expected to support the ‘evergreen’ local COVID vaccination programme with the preparation and administration of vaccines, including clinical eligibility assessment, consent, administration and aftercare advice, in line with the relevant prescribing mechanism (e.g. National Protocol), within the scope of professional practice and with training.
This is not intended to be an exhaustive list of responsibilities, and it is expected that you will participate in a wide range of activities.
Person Specification
Education, Training and Qualifications
* Maths and English GCSE (Grade C and above) or equivalent - Essential
* Registered Healthcare Professional, with either the NMC or HCPC - Essential
* Degree level education - Essential
* Post registration qualification in relevant area - Essential
* Masters degree or equivalent experience gained by undertaking on-going personal development and training - Desired
* Teaching and assessing qualification - Essential
* Management/Leadership Qualification/development programme - Desired
Skills and Abilities
* Excellent written and verbal communication and interpersonal skills- Essential
* Enhanced clinical skills- Essential
* Ability to advocate on patient issues- Essential
* Ability to demonstrate leadership skills- Essential
* Organisational and prioritisation skills: including the ability to make decisions and to prioritise- Essential
* Ability to understand and interpret research findings/evidence based care and apply to practice- Essential
* Good working knowledge of health and safety and risk management, including lone working- Essential
* Computer literate including emails and spreadsheets- Essential
Experience
* Significant relevant experience in frailty and proactive long term condition management- Essential
* Experience of caseload management including responsibility for complex assessment and management of vulnerable people- Essential
* Experience, underpinned by knowledge of working with and understanding the complex needs of patients in a primary care/community setting - Desired
* Involved in the implementation and management of change - Desired
* Evidence of innovative practice - Desired
* Participates in regular clinical supervision - Essential
* Experience of working with long-term conditions and frailty - Essential
Knowledge and Understanding
* Good understanding of current nursing and AHP workforce issues - Essential
* Clear understanding of Primary & Community health services - Essential
* Demonstrates an understanding and insight into current issues and developments within the NHS - Essential
Personal Qualities/ Other
* Car driver with valid licence - Essential
* Reliable and flexible - Essential
* Ability to work well in stressful situations - Essential
* Innovative and adaptable - Essential
* Assertive - Essential
* Commitment to attend forms or training as learning needs are identified - Essential
Job Types: Full-time, Part-time, Permanent
Pay: From £35,391.00 per year
Expected hours: No less than 21 per week
Benefits:
* Company pension
* Employee discount
* Free parking
* Health & wellbeing programme
* On-site parking
* Referral programme
Shift:
* Day shift
Work days:
* Monday to Friday
Work Location: In person
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