Job summary
An exciting opportunity has arisen for an
experienced practitioner to lead the Integrated Care service and Social Prescribing Link Worker (SPLW) outputs within Dryland
Surgery. You will be the key decision-maker for the people whose care you are
supporting, operating as a go-to person for the practice to ensure that their
collaborative care is timely and seamless, and that everyone involved is
working together. Your support will enable health and wellbeing, support behaviour change
to achieve a healthy lifestyle, and address health inequalities.
You will work closely with the GPs and other
primary care professionals within the practice and the wider NHS - including
community groups, Adult Social Care and Age UK - to identify and manage a
caseload of identified patients - that includes young people and frail, elderly
service users - making sure that appropriate support is made available to them
and their carers, and ensuring that their changing needs are addressed.
Main duties of the job
As an autonomous practitioner, you'll work with and support
individuals to identify their needs, develop personalised care and support
plans, build up their resilience, and increase their active involvement with
their local communities. As a social
prescriber, you'll review plans with your service users at regular intervals
to capture progress, ensure they remain appropriate for the individual.
You will work
collaboratively with local partners and communities to identify local community
assets (Voluntary, Community and Social Enterprise (VCSE) organisations).
The successful candidate will also:
Take overall responsibility for coordination and
delivery of the Frailty MDT meetings, ensuring that all new referrals are
identified.
Utilise population health intelligence to deliver personalised
care.
Support patients ina Shared Decision-Making conversation.
Holistically bring together all of a persons
identified care and support needs, and explore options to meet these within a
single personalised care and support plan (PCSP), in line with best
practice, based on what matters to the person.
Help people make choices about their
care.
Forge strong links with a wide
range of local VCSE organisations, community and neighbourhood level groups, creating a
menu of diverse community groups and assets, who promote diversity and
inclusion.
About us
Primary Care Teams are growing and evolving and now
seeking more staff to deliver the care services to our patients. You would lead
a 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 enhancing
patient services in the local community.
Vibrant, friendly working atmosphere with great
opportunities
Our ethos includes:
Supporting patients to utilise decision aids in preparation for a
shared decision-making conversation.
Holistically bringing together all of a persons identified care and
support needs, and exploring options to meet these within a single personalised
care and support plan (PCSP), in line with PCSP best practice, based on what
matters to the person.
Helping people to manage their needs through answering queries, making
and managing appointments, and ensuring that people have good quality written
or verbal information to help them make choices about their care.
Supporting people to take up training and employment, and to access
appropriate benefits where eligible.
Supporting people to understand their level of knowledge, skills
and confidence when engaging with their health and wellbeing.
Job description
Job responsibilities
Take overall responsibility for coordination and delivery of the MDT
meetings.
A key role of the Care Coordinator will be to schedule the MDT meetings,
manage the meeting agenda items; ensuring that all new referrals are
identified, and information circulated to team members in advance of the
meeting. Utilise population health intelligence and PCN / Partner data to
proactively identify and work with a cohort of patients to deliver personalised
care.
Support patients to utilise decision aids in preparation for a shared
decision-making conversation.
Holistically bring together all of a persons identified care and support
needs, and explore options to meet these within a single personalised care and
support plan (PCSP), in line with PCSP best practice, based on what matters to
the person.
Help people to manage their needs through answering queries, making and
managing appointments, and ensuring that people have good quality written or
verbal information to help them make choices about their care.
Support people to take up training and employment, and to access
appropriate benefits where eligible.
Support people to understand their level of knowledge, skills and
confidence when engaging with their health and wellbeing.
Assist people to access self-management education courses, peer support
or interventions that support them in their health and wellbeing and increase
their activation level.
Explore and assist people to access personal health budgets where
appropriate.
Provide coordination and navigation for people and their carers across
health 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 practice
to identify and manage a caseload of patients, and where required and as
appropriate, refer people back to other health professionals.
Raise awareness of how to identify patients who may benefit from shared
decision making and support staff and patients to be more prepared to have
shared decision-making conversations.
Job description
Job responsibilities
Take overall responsibility for coordination and delivery of the MDT
meetings.
A key role of the Care Coordinator will be to schedule the MDT meetings,
manage the meeting agenda items; ensuring that all new referrals are
identified, and information circulated to team members in advance of the
meeting. Utilise population health intelligence and PCN / Partner data to
proactively identify and work with a cohort of patients to deliver personalised
care.
Support patients to utilise decision aids in preparation for a shared
decision-making conversation.
Holistically bring together all of a persons identified care and support
needs, and explore options to meet these within a single personalised care and
support plan (PCSP), in line with PCSP best practice, based on what matters to
the person.
Help people to manage their needs through answering queries, making and
managing appointments, and ensuring that people have good quality written or
verbal information to help them make choices about their care.
Support people to take up training and employment, and to access
appropriate benefits where eligible.
Support people to understand their level of knowledge, skills and
confidence when engaging with their health and wellbeing.
Assist people to access self-management education courses, peer support
or interventions that support them in their health and wellbeing and increase
their activation level.
Explore and assist people to access personal health budgets where
appropriate.
Provide coordination and navigation for people and their carers across
health 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 practice
to identify and manage a caseload of patients, and where required and as
appropriate, refer people back to other health professionals.
Raise awareness of how to identify patients who may benefit from shared
decision making and support staff and patients to be more prepared to have
shared decision-making conversations.
Person Specification
Qualifications
Essential
- Professional clinical qualifications or competencies commensurate to a Band 7 AfC appointment.
- GCSE or equivalent grade C level qualification in Maths and English.
- Experience Minimum of one years' experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field.
- Experience of coordinating and liaising with multiple stakeholders or individuals to meet specified outcomes.
- Experience providing advice/signposting to patients.
- Experience of undertaking quality improvement activity.
- Excellent organisational and administration skills.
- Ability to analyse and interpret information and present results in a clear and concise manner.
- Able to prioritise and manage own workload.
Desirable
- Experience of working in a multi-disciplinary setting where influence and negotiation is required.
- Experience of using technology and digital tools to support health and wellbeing.
- Experience of co-production with patients or service-users.
- Skills and Knowledge Excellent influencing and negotiating skills.
Experience
Essential
- Experience working within a healthcare setting and interacting with patients.
- Ability to manage own outputs and wider MDT's workload.
- Recognition of priorities and sound time/resource management
- Excellent influencing and negotiating skills.
Person Specification
Qualifications
Essential
- Professional clinical qualifications or competencies commensurate to a Band 7 AfC appointment.
- GCSE or equivalent grade C level qualification in Maths and English.
- Experience Minimum of one years' experience of working with healthcare professionals and or previous experience in the NHS or social care or relevant field.
- Experience of coordinating and liaising with multiple stakeholders or individuals to meet specified outcomes.
- Experience providing advice/signposting to patients.
- Experience of undertaking quality improvement activity.
- Excellent organisational and administration skills.
- Ability to analyse and interpret information and present results in a clear and concise manner.
- Able to prioritise and manage own workload.
Desirable
- Experience of working in a multi-disciplinary setting where influence and negotiation is required.
- Experience of using technology and digital tools to support health and wellbeing.
- Experience of co-production with patients or service-users.
- Skills and Knowledge Excellent influencing and negotiating skills.
Experience
Essential
- Experience working within a healthcare setting and interacting with patients.
- Ability to manage own outputs and wider MDT's workload.
- Recognition of priorities and sound time/resource management
- Excellent influencing and negotiating skills.
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.