High Intensity User Care Coordinator

Job description

Job responsibilities

Job Description

Main Responsibilities

1. Identify patients classified as high intensity users via data from primary care, emergency departments, and other services.

2. Work one-to-one with individuals to develop personalised care plans aimed at addressing root causes of frequent service use.

3. Coordinate input from multiple agencies e.g., GPs, A&E, mental health, drug and alcohol services, housing, voluntary support.

4. Serve as the single point of contact for the patient and professionals involved in their care.

5. Promote continuity of care and monitor implementation of care plans, updating as needed in collaboration with MDT partners.

6. Facilitate smooth transitions between care settings, especially from emergency or acute settings back into community-based support.

7. Provide case management, ensuring timely referrals, follow-up, and documentation in appropriate systems.

8. Track outcomes and gather data to assess the impact of interventions on patient wellbeing and service use.

9. Liaise with system partners to identify service gaps and develop better integrated approaches for supporting HIUs.

10. Managing operational meeting processes, identifying patients for discussion and working closely with clinicians to define and lead the meetings. Organise and attend relevant meetings when required including multi-disciplinary team meetings, ensure a programme of regular meetings is established, ensuring that all necessary documentation is circulated in advance.

11. Ensure that meeting actions are recorded, disseminated and followed up in a timely way; ensure relevant practitioners are aware of meeting decisions and actions / outcomes, and chase for action resolution and update.

Key Tasks

1. Enable access to personalised care and support:

a. Take referrals for individuals or proactively identify people who could benefit from support through HIU care coordination;

b. Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs;

c. Support people to develop and implement personalised care and support plans; build trusting relationships with patients and act as an advocate where needed

d. Engage patients in exploring alternatives to emergency care through support and education.

e. Support patients to access appropriate mental health, addiction, housing, or social services.

f. Use data to monitor patient progress, flag concerns, and escalate complex cases appropriately.

g. Maintain accurate records using clinical systems and ensure activity is coded correctly (e.g., SNOMED).

h. Contribute to the development and improvement of local HIU pathways and support models.

2. Co-ordinate and integrate care:

a. Help people transition seamlessly between services and support them to navigate through the health and care system;

b. Refer onwards to social prescribing link workers where required;

c. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported;

d. Actively participate in multidisciplinary team meetings in the PCN as and when appropriate;

e. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.

Additional Duties

In addition to the above duties you will also be expected to perform the below key activities in line with your job role:

Complete mandatory training in line with PCN policy and procedures

To participate in the staff appraisal process

To keep yourself updated on all matters relating to PCN policy

NHS Constitution

You are responsible for ensuring that the values outlined in the NHS Constitution are adhered to daily and any matters of concern are raised with your Line Manager or through the necessary processes within the PCN. You are responsible for delivering a compassionate, dignified and respectful service to patients at all times.

Duty of Candour

You must adhere to the principles of openness, transparency and the statutory duty of candour in your day to day work and conduct and encourage the same behaviours within the PCN.

Infection Control

The post holder is accountable and responsible for the prevention of healthcare associated infections by complying with all Infection Prevention & Control policies and procedures in line with legislation (Health Act 2006; Code of Practice for the Prevention and Control of Healthcare Associated Infections).

Health and Safety

All employees must be aware of the responsibilities placed upon them under the Health and Safety at Work Act (1974) to ensure that the agreed safety procedures are carried out to provide a safe environment for employees and visitors.

GDPR

The General Data Protection Regulation requires you to ensure compliance with all relevant policies and those procedures relevant to the area of work. The PCN will always seek to process your personal data in accordance with its obligations and your rights.

Confidentiality

Your attention is drawn to the confidential nature of information collected and used throughout the NHS. The unauthorised use of disclosure of patient, staff or other personal information is a dismissible offence. The unauthorised disclosure of information could also result in a prosecution for an offence, or action for civil damages, under the General Data Protection Regulation. You are required to observe the strictest confidence regarding any Confidential Information relating to work of the PCN, its patients and its employees.

Risk Management

All staff working in, or for the PCN have a responsibility for participating in the risk management programme. All post-holders have a responsibility to assess all risks to systems, processes and environment and contribute to the clinical and corporate governance agendas as appropriate.

Safeguarding Duty

It is the responsibility of the post holder to be aware of and follow the legislation and guidance regarding Safeguarding Children and Adults. The post holder is responsible for ensuring they receive the appropriate level of Safeguarding training according to their role.

Information Technology

It is the responsibility of the post holder to have a level of IT competence relevant to their job role and will be expected to continue to keep their skills up to date as part of their Continuing Professional Development.

Changes to this Job Description

Post holders have a responsibility to discuss any significant job changes with their line manager at the time the change occurs and agree any permanent substantial change. The Job Description does not purport to be an exhaustive list of duties and responsibilities. The post holder will be expected to undertake additional duties as the requirements of the post change.

Person Specification

Qualifications

Essential

• Good standard of education with 5 C/GCSEs or equivalent
• Ability to use Microsoft Office applications Word, Excel, PowerPoint, Outlook

Desirable

• NVQ Level 3 in adult care - advanced level or equivalent qualifications or working towards
• Evidence of continuing professional development

Experience

Desirable

• Knowledge/experience of clinical medical systems
• Knowledge/experience of SystmOne
• Experience of working in the NHS and preferably General Practice
• Experience of communication with patients and vulnerable individuals
• Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement
• Experience of supporting people, their families and carers in a related role
• Experience supporting adults with complex needs (e.g., mental health, addiction, homelessness)

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 details

Employer name

Rosebank Health

Address

Kingsway Health Centre

Rudloe Drive, Kingsway

Gloucester

Gloucestershire

GL2 2FY

Employer's website

https://www.rosebankhealth.nhs.uk/ (Opens in a new tab)