Job summary
TheProactive Care Practitioner will provide a responsive, safe, effective caring ProactiveCare service. The service aims tosupport an identified cohorts of people living with mild to moderate frailtyand long term conditions, providing comprehensive assessment and proactive casemanagement.
Thiswill include adopting a shared decision making approach and supportingself-management through sign-posting, health coaching and social prescribing,MDT discussion and onward referral as required.
TheProactive Care service, whilst operating from a local hub, will require travelto Practices or patients homes across the Surrey Heath PCN geography.
Main duties of the job
To work closely with the Integrated Care Team,Frailty MDT and local GP teams to provide proactive care services for patientswith frailty or those with a long term condition identified as requiring ananticipatory approach.
To support the identification of the target cohortfor whom there is the greatest potential impact on health and system outcomes.
To provide specialist assessment of patients, usinganalytical and judgment skills. To provide appropriate patient centredtreatment using evidence based practice where-ever possible. Patients willpresent with acute or chronic conditions and complex multi-system pathologies neuro, respiratory conditions, orthopaedic rehabilitation and age relateddeterioration.
To ensure holistic assessment using an agreedapproach, such as comprehensive geriatric assessment (CGA).
To devise effective personalised care plans for eachpatient with specific therapeutic knowledge, recognising him or her as anindividual. The plan of care, which has been developed in conjunction with thepatient, carer and relevant others, should be outcome based and ensureappropriate pathways of care and communication via liaison and referral toother agencies as required.
About us
Weare Surrey Heath Community Providers Limited, which is a federation of 7 GPpractices across 10 sites, covering a population of over 103,000 patientsacross Surrey Heath. We began in 2016 and now employ around 200 members ofstaff across our head office sites, and our primary care and unplanned careservices.
Asa GP Federation, we are proud to represent our member practices and to championprimary care by working with local general practice and system partners in theprovision of community-based healthcare services. We are dedicated to providingsafe and compassionate care to our patients across our range of primary careand unplanned healthcare services in Surrey Heath, and believe in continuouscommitment to quality service delivery and positive patient outcomes.
Patients are at the heart ofeverything we do, and we pride ourselves in ensuring our patients feel safe, supported,communicated with and respected, at a time when they may be feelingvulnerable. Our vision is to provide high quality, seamless health care thatenables people to lead healthier lives, whilst feeling supported and cared for.
Job description
Job responsibilities
Please refer to Supporting Documents for full Job Description, list of responsibilities and person specification.
Person Specification
Education, Training and Qualifications
Essential
1. Maths and English GCSE'S (C and above) or equivalent.
2. Registered Healthcare Professional, with either the NMC or HCPC.
3. Degree level education.
4. Post Registration qualification in relevant area.
5. Teaching and assessing qualification.
Desirable
6. Masters degree or equivalent experience gained by undertaking on-going personal development and training. Management/Leadership Qualification/development programme.
Experience
Essential
7. Significant relevant experience in frailty and proactive long term condition management. Experience of caseload management including responsibility for complex assessment and management of vulnerable people. Participates in regular clinical supervision. Experience of working with long-term conditions and frailty.
Desirable
8. Experience, underpinned by knowledge of working with and understanding the complex needs of patients in a primary care/community setting. Involved in the implementation and management of change. Evidence of innovative practice.
Knowledge and Understanding
Essential
9. Good understanding of current nursing and AHP workforce issues. Clear understanding of Primary & Community health services. Demonstrates an understanding and insight into current issues and developments within the NHS.
Other
Essential
10. Car driver with valid licence. Reliable and flexible. Ability to work well in stressful situations. Innovative and adaptable. Assertive. Commitment to attend forms or training as learning needs are identified.
Skills and Abilities
Essential
11. Excellent written and verbal communication and interpersonal skills
12. Enhanced clinical skills. Ability to advocate on patient issues. Ability to demonstrate leadership skills. Organisational and prioritisation skills: including the ability to make decisions and to prioritise. Ability to understand and interpret research findings/evidence based care and apply to practice. Good working knowledge of health and safety and risk management, including lone working. Computer literate including emails and spreadsheets.