Job summary
We are recruiting passionate and proactive Caseworkers to
join the Lewisham Integrated Neighbourhood Teams (INTs). This is an exciting
opportunity to play a key role in delivering community-based, person-centred
care for residents with complex needs focusing on holistic assessments, care
coordination, and addressing health inequalities.
You'll work as part of a multi-agency team supporting
residents with three or more long-term conditions, linking them to health,
social care, and voluntary sector services. Acting as a critical link between health, social care, and community services, the INT Caseworker will ensure seamless, person-centred care that tackles health inequalities.
Main duties of the job
Main Duties and Responsibilities
Manage a caseload of residents with complex needs using a population health approach.
Conduct holistic assessments and develop personalised support plans.
Coordinate care and referrals between GPs, hospitals, social care, and community organisations.
Attend MDT meetings and advocate for patients' needs.
Support digital inclusion and contribute to continuous service improvement.
Person Specification (Summary)
Essential
Experience in health, social care, or community coordination.
Strong communication and organisational skills.
Ability to complete holistic assessments and coordinate services.
Proficiency in IT and digital tools.
About us
The Lewisham Health and Care Partnership is committed to creating a sustainable health and care system that supports both physical and mental wellbeing. Our Integrated Neighbourhood
Teams bring together NHS services, primary care, social care, and the voluntary sector to provide coordinated, community-based support.
Successful candidate will be employed by Sevenfields Primary Care Network (PCN) and Ravensbourne PCN and align to a neighbourhood-based INT.
Sevenfields PCNis a collaboration of four GP practices serving a population of 41,000 patients. Ravensbourne PCN comprises two GP practices operating across three sites, supporting 31,000 patients. Both PCNs are located in South Lewisham and are committed to delivering community-focused healthcare, tackling health inequalities, and improving outcomes for the areas diverse population.
Job description
Job responsibilities
Duties & Responsibilities
Population Health and Caseload Management
- Analyse and assess population health data to identify high priority patients or cohorts for INT intervention.
- Manage and maintain the INT caseload, ensuring efficient prioritisation and monitoring of patient progress.
- Collaborate with multidisciplinary teams (MDTs) to coordinate and manage patient support plans.
Holistic Patient Assessments
- Conduct holistic assessments with patients to understand their health, social care, and personal support needs.
- Work with patients to set achievable goals and identify solutions that promote independence and wellbeing.
- Use an evidence based approach to recognise patient priorities and encourage self management wherever possible.
- Provide follow up holistic assessments prior to patient discharge from the INT service
Service Linkage and Signposting
- Provide effective signposting for low intervention patients to one off or community based support services.
- Act as a coordinator between various services, including primary care, secondary care, social care, mental health, and voluntary sector organisations.
- Ensure patients are connected with the most appropriate support resources to address their individual needs.
Integrated Working and Coordination
- Participate in INT and MDT meetings to represent patient needs and advocate for their voice in care planning.
- Actively support care coordination by liaising with GPs, hospital teams, social care, and community organisations.
- Maintain accurate and up-to-date records of interventions, referrals, and progress in patient care plans.
IT and Communication
- Utilise digital tools and IT systems to streamline communication and record patient data accurately.
- Address interface challenges between IT systems to ensure seamless information sharing across teams and organisations.
- Promote digital inclusion by supporting patients in accessing online services and tools where applicable.
Community Engagement and Partnership
- Build strong relationships with local voluntary and community organisations to enhance the range of support available to patients.
- Work with partnership organisations to refine and improve pathways, ensuring effective collaboration.
- Gather feedback from patients and partners to continuously improve service delivery and address local needs.
Working Relationships and Contacts
Lifestyle Medicine Community of Practice Lead
Integrated Neighbourhood Core Team
General Practitioners (GPs)
Social Prescribing Link Workers
Care Coordinators
Community Link Workers
Other health professionals within the PCN Network Contract Directed Enhanced Service (DES)
The post holder is expected to work core hours but should also be flexible around service needs, which may include some evenings and weekends.
Job description
Job responsibilities
Duties & Responsibilities
Population Health and Caseload Management
- Analyse and assess population health data to identify high priority patients or cohorts for INT intervention.
- Manage and maintain the INT caseload, ensuring efficient prioritisation and monitoring of patient progress.
- Collaborate with multidisciplinary teams (MDTs) to coordinate and manage patient support plans.
Holistic Patient Assessments
- Conduct holistic assessments with patients to understand their health, social care, and personal support needs.
- Work with patients to set achievable goals and identify solutions that promote independence and wellbeing.
- Use an evidence based approach to recognise patient priorities and encourage self management wherever possible.
- Provide follow up holistic assessments prior to patient discharge from the INT service
Service Linkage and Signposting
- Provide effective signposting for low intervention patients to one off or community based support services.
- Act as a coordinator between various services, including primary care, secondary care, social care, mental health, and voluntary sector organisations.
- Ensure patients are connected with the most appropriate support resources to address their individual needs.
Integrated Working and Coordination
- Participate in INT and MDT meetings to represent patient needs and advocate for their voice in care planning.
- Actively support care coordination by liaising with GPs, hospital teams, social care, and community organisations.
- Maintain accurate and up-to-date records of interventions, referrals, and progress in patient care plans.
IT and Communication
- Utilise digital tools and IT systems to streamline communication and record patient data accurately.
- Address interface challenges between IT systems to ensure seamless information sharing across teams and organisations.
- Promote digital inclusion by supporting patients in accessing online services and tools where applicable.
Community Engagement and Partnership
- Build strong relationships with local voluntary and community organisations to enhance the range of support available to patients.
- Work with partnership organisations to refine and improve pathways, ensuring effective collaboration.
- Gather feedback from patients and partners to continuously improve service delivery and address local needs.
Working Relationships and Contacts
Lifestyle Medicine Community of Practice Lead
Integrated Neighbourhood Core Team
General Practitioners (GPs)
Social Prescribing Link Workers
Care Coordinators
Community Link Workers
Other health professionals within the PCN Network Contract Directed Enhanced Service (DES)
The post holder is expected to work core hours but should also be flexible around service needs, which may include some evenings and weekends.
Person Specification
Qualifications
Essential
- Good general education with English and Maths to GCSE standard or equivalent
- Relevant NVQ 3 or equivalent qualification or experience
Experience
Essential
- Experience in health, social care, or community coordination.
- Strong communication and organisational skills.
- Ability to complete holistic assessments and coordinate services.
- Proficiency in IT and digital tools.
Skills and Abilities
Essential
- Strong organisational skills to manage caseloads and prioritise tasks effectively
- Excellent interpersonal and communication skills for working with patients, families, and multidisciplinary teams
- Analytical skills to assess population health data and identify target groups for intervention
- Ability to conduct person-centred assessments and create individualised care plans
- Knowledge of the health and social care system, including voluntary sector services
- Proficiency in IT systems and digital tools for care coordination and reporting.
- Problem-solving skills to address various challenges
Desirable
- Trained in phlebotomy and health care checks.
- Can speak multiple languages
Skills and Abilities
Essential
- Strong organisational skills to manage caseloads and prioritise tasks effectively
- Excellent interpersonal and communication skills for working with patients, families, and multidisciplinary teams
- Analytical skills to assess population health data and identify target groups for intervention
- Ability to conduct person-centred assessments and create individualised care plans
- Knowledge of the health and social care system, including voluntary sector services
- Proficiency in IT systems and digital tools for care coordination and reporting.
- Problem-solving skills to address various challenges
Desirable
- Trained in phlebotomy and health care checks.
- Can speak multiple languages
Person Specification
Qualifications
Essential
- Good general education with English and Maths to GCSE standard or equivalent
- Relevant NVQ 3 or equivalent qualification or experience
Experience
Essential
- Experience in health, social care, or community coordination.
- Strong communication and organisational skills.
- Ability to complete holistic assessments and coordinate services.
- Proficiency in IT and digital tools.
Skills and Abilities
Essential
- Strong organisational skills to manage caseloads and prioritise tasks effectively
- Excellent interpersonal and communication skills for working with patients, families, and multidisciplinary teams
- Analytical skills to assess population health data and identify target groups for intervention
- Ability to conduct person-centred assessments and create individualised care plans
- Knowledge of the health and social care system, including voluntary sector services
- Proficiency in IT systems and digital tools for care coordination and reporting.
- Problem-solving skills to address various challenges
Desirable
- Trained in phlebotomy and health care checks.
- Can speak multiple languages
Skills and Abilities
Essential
- Strong organisational skills to manage caseloads and prioritise tasks effectively
- Excellent interpersonal and communication skills for working with patients, families, and multidisciplinary teams
- Analytical skills to assess population health data and identify target groups for intervention
- Ability to conduct person-centred assessments and create individualised care plans
- Knowledge of the health and social care system, including voluntary sector services
- Proficiency in IT systems and digital tools for care coordination and reporting.
- Problem-solving skills to address various challenges
Desirable
- Trained in phlebotomy and health care checks.
- Can speak multiple languages
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.
