Job summary
Are you looking for a new challenge? We are recruiting 2 x High Intensity User (HIU) Leads to workdirectly with the HIU client group, delivering a service with a highly personalised approach that supports improved wellbeing and health outcomes, whilst reducing inappropriate contact with health care services and unscheduled care in particular. The HIU Lead will lead a service with a focus on supporting the HIU client group to flourish through sustaining job opportunities, reconnecting with families, improving well-being etc.
HIU are a relatively small percentage of individuals who are know to generate a disproportionately high percentage of A&E attendances, hospital admissions and contact with primary care. The HIU Lead will be a highly motivated, emotionally intelligent and resilient person with leadership skills whose drive is quality client care and who thrives off innovation. Thinking "out of the box" is encouraged to support this vulnerable client group.
Main duties of the job
Identify those at greatest risk of A&Eattendance and non-elective admissions.
Proactively work with a rolling cohort of HIUclients, really understanding what they need.
To coordinate wellbeing and connect with otherservices, enrolling them to help to get to the desired end.
Reducing 999 calls as a natural by-product(possibly ambulance and police).
Reducing A&E attendances and avoidablenon-elective admissions
Driveequality and client voice.
Formingrobust network of community health, social care, mental health and police tomanage clients, creating true integrated working.
Providing aservice driven by quality with positive human outcomes observed.
Act as aconduit to negotiate and de-escalate issues before a crisis occurs; a situationwhich has historically led to a destabilisation of their condition andresulting in a A&E attendance / 999 calls.
Improving communicationand partnership working between those involved in client care 24/7.
Identifypatterns and causal factors which trigger relapse behaviours in order toshape future commissioning of service and/or demand/capacity planning.
Empowerclients to self-manage to enable sustainable discharge.
About us
The team at Boston PCN work collaboratively to provide services in addition to those already found at local GP practices. Primary care networks have the potential to benefit patients by offering improved access and extending the range of services available to them and by helping to integrate primary care with wider health and community Primary Care Networkbrings together several GP practices, health and care partners, patient organisations and the voluntary sector across Boston.
Our Vision :Our vision is a community where everyone feels valued, has a sense of belonging and can achieve what is important to them.
Our Mission :Our mission is to join up our practices with other health and care providers, charities and community groups, so that everyone in our community receives the level of support they need, when they need it, close to their home.
Our Values :
1. We put people at the centre of all that we do
2. We are united in purpose standing together; one team, one voice, one heart
3. We build trust and are honest, acting with integrity and compassion
4. We are inclusive, valuing and championing diversity
5. We are brave to positively challenge the status quo to bring innovation and real change for a better future
6. We are responsible, using our existing strengths and assets effectively and bringing new resources to level up our community
Job description
Job responsibilities
Key Tasks and Responsibilities
1. To provide holistic one to one person centred support for people aged 18 and over who have high dependency on emergency services and who are frequent visitors/ callers of A&E, the Urgent Care Centre and East Midlands Ambulance Service.
Carry out the role of a facilitator, broker, sign poster, community connector and navigator, acting as an enabler between the voluntary and community sector, patients, GPs and health clinicians, and social care.
Provide support to patients, generally in their own homes, up to 3-4 months to help direct and connect them to alternative sources of non-medical support services and activities.
Offer a personalised approach to sensitively uncover the real reasons for them calling 999 or presenting frequently at A&E/UCC.
During client visits undertake an assessment to gather baseline data and to identify the support needs and actions. Generating personalised care and support or wellbeing plans, which may include risk management.
Ensure support actions agreed with the patient are carried out by the service. Support areas could include making referrals into a range of services provided by the voluntary, statutory or private sector, help with non-means tested benefit form filling Personal Independent Payments, Attendance Allowance, housing forms etc, distributing food bank vouchers, identifying suitable volunteering opportunities, connecting people into peer to peer led activities, initially taking patients to services if their confidence is low etc.
Once support has been provided carry out a final assessment
2. To meet and collaborate with A&E clinical staff regularly, to discuss, identify and agree appropriate referrals from the patient cohort list (patients presenting more than 12 times per year) and other patients presenting less than 12 times per year at A&E.
Meet with a range of health clinicians to discuss and agree appropriate referrals from the patient cohort list.
Build and maintain positive relationships with a range of health professionals.
Work closely with health clinicians to facilitate optimal joint working on safe and effective care for patients with complex needs.
Raise awareness of voluntary and community sector activities and services on offer to showcase the diverse range of services available to health and social care practitioners.
Raise awareness of the social prescribing service with health practitioners.
With health professionals and a range of providers identify service needs, broker solutions and when required enable individuals to be supported to kick start/lead on new activities through Lincolnshire CVS.
3. To work and collaborate with the voluntary and community sector to help identify appropriate referral destinations and to explore opportunities to meet gaps in services and activities.
Keep abreast of a wide range of support services on offer in the voluntary and community sector through undertaking research, making connections with organisations and groups and by using a range of local online directories and Community Connectors.
Build and maintain positive relationships with a wide range of voluntary and community sector providers.
When gaps is services and activities are identified discuss and raise these with the team and if required liaise with voluntary organisations and Community Connector to help identify solutions.
4. To ensure effective record keeping and storage of patient data to demonstrate outputs and outcomes which is compliant with GDPR.
Ensure all patient records and actions are entered onto our record keeping systems.
Ensure GDPR requirements are adhered to in relation to data management.
When required, support in gathering any data required for working out cost savings to the wider health and social care sector as a result of the service interventions.
5. To actively contribute as a member of a well-established social prescribing and Neighbourhood team who support the most vulnerable in society.
Actively contribute to team meetings, away days, planning activities and reflective practice activities.
Share progress, learning and challenges within the existing Integrated Plus social prescribing team.
Share ideas about how the service could develop and evolve.
Adhere to all Boston PCN policies and procedures lone working, patient consent, information governance, and local governance policy and procedure etc.
Person Specification
Qualifications
Essential
7. Experience of supporting vulnerable adults in a person centred way
8. You have the ability to work sensitively in difficult emotional circumstances with empathy, compassion, respect and understanding.
9. Knowledge of asset/strength-based recovery models and approaches
10. Experience of case load management.
11. You will be able to cooperate with a range of health professionals, voluntary sector providers and people around the range of possibilities that might be available in enabling service provision to be more holistic to improve mental health and wellbeing of vulnerable people.
Desirable
12. Motivational interviewing
13. Coaching for Health and Wellbeing
14. Personalised Care Institute e-learning modules PCSP, shared decision making or equivalent
15. Experience of working in the voluntary and community sector
Experience
Essential
16. Excellent communication and interpersonal skills.
17. Experience of working in teams
18. Experience of collaborative working
19. Knowledge and understanding of equality and diversity
20. Knowledge and understanding of GDPR
21. You can plan, prioritise and carry out your work in a flexible way. You are accustomed to working on your own and in teams.
22. You know how to use a range of software to produce written documents, spreadsheets, presentations. You can effectively manage communication by email, and you are comfortable using collaborative online tools (for example WhatsApp, Twitter, Facebook, using text editors such as Word/Pages and other message apps.
23. Adaptability, flexibility and ability to cope with uncertainty and change
24. Demonstrate ability to work in a busy environment; ability to deal with both urgent and important tasks and to prioritise effectively whilst also supporting others
25. Excellent time keeping and prioritisation skills
Desirable
26. Experience of providing social prescribing interventions
27. Knowledge of health and social care
28. Local knowledge of the voluntary and community sector
29. Ability to use Microsoft 365
30. Specific Aptitudes Awareness of equality and valuing diversity principles Understanding of Confidentiality and Data Protection Act
31. Self-motivated and proactive
32. Continued commitment to improve skills and ability in new areas of work
33. Able to undertake the demands of the post with reasonable adjustments if required
34. Ability to work from home on some occasions where tasks allow