Job summary
Are you looking for a new challenge? We are excited to
recruit a full-time High Intensity User (HIU) Lead to support the launch of our
new High Intensity Use (HIU) Service, a pioneering initiative within our Primary
Care Network (PCN), made up of four GP practices working in close partnership
with neighbourhood teams.
The HIU Service supports individuals who frequently attend
A&E or use emergency services more than expected. Many face complex
challenges including poor physical or mental health, housing instability,
loneliness, or substance misuse. This service takes a person-centred approach,
building trusted relationships and offering long-term, practical support to
help people access the appropriate care and improve their quality of life. The
HIU Lead will work directly with the HIU client group, delivering a highly personalised
approach that aims to improve wellbeing and health outcomes, whilst reducing
inappropriate contacts with healthcare services, particularly unscheduled care.
The HIU Lead will be dedicated to helping and supporting the HIU client group
to thrive, by fostering job opportunities, reconnecting with families,
improving overall well-being.
The ideal candidate will be a highly motivated, emotionally
intelligent, compasstionate and resilient individual with strong leadership
skills. A commitment to high-quality client care and a passion for innovation.
We encourage thinking "out of the box" to effectively support this
vulnerable group.
Main duties of the job
This is a non-clinical role focused on listening,
understanding, and empowering.
Identify those at greatest risk of A&E attendance and
non-elective admissions.
Proactively work with a rolling cohort of HIU clients,
really understanding what they need. Working with them in their homes or GP practice.
To coordinate wellbeing and connect with other services,
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 avoidable non-elective
admissions.
Drive equality and client voice.
Forming robust network of community health, social care,
mental health and police to manage clients, creating true integrated working.
Providing a service driven by quality with positive human
outcomes observed.
Act as a conduit to negotiate and de-escalate issues before
a crisis occurs; a situation which has historically led to a destabilisation of
their condition and resulting in a A&E attendance / 999 calls.
Improving communication and partnership working between
those involved in client care 24/7.
Identify patterns and causal factors which trigger relapse
behaviours in order to shape future commissioning of service and/or
demand/capacity planning.
Empower clients to self-manage to enable sustainable
discharge.
About us
Meridian Medical Primary Care Network is a
group of GP Practices coming together to share their experience, workforce and
services, with the aim of improving access and meeting the needs of local
patients and communities. In doing this, we can provide better quality services,
closer to where patients live and are varied to meet their needs.
The four GP Practices are: East Lindsey Medical Group in Louth &
Tetford, James Street Family Practice in Louth, Marsh Medical Practice in North
Somercotes and Manby and Tasburgh Lodge in Woodhall Spa, who all work together to deliver the best possible care for our patients, along with health and care partners, LCHS, patient organisations and the voluntary sector across Lincolnshire, as well as working across borders. The PCN serves a population of approximately
39,000 patients.
You will be employed by East Lindsey Medical Group and due
to the geography of the PCN, business travel to undertake the role will be
paid.
The role will support Meridian Medical PCN and its GP
practices and neighbourhood teams and truly encompass the future of
neighbourhood working.
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.
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 ,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 e.g. 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 in 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 Meridian Medical PCN policies and procedures
e.g. lone working, patient consent, information governance, and local
governance policy and procedure etc.
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 ,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 e.g. 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 in 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 Meridian Medical PCN policies and procedures
e.g. lone working, patient consent, information governance, and local
governance policy and procedure etc.
Person Specification
Qualifications
Essential
- Essential Qualifications
- -No formal qualifications are required but you must have high emotional intelligence and resilience, be a win-win negotiator, and be brave enough to change the culture around high-intensity use of services.
- -The candidate needs to shine and connect well in interviews to demonstrate these skills.
- -Motivational interviewing
- -Coaching for Health and Wellbeing
- -Personalised Care Institute e-learning modules, PCSP, shared decision making or equivalent.
Experience
Essential
- -Experience of supporting vulnerable adults in a person-centred way.
- -Experience of working in the voluntary and community sector.
- -You have the ability to work sensitively in difficult emotional circumstances with empathy, compassion, respect and understanding.
- -Knowledge of asset/strength-based recovery models and approaches
- -Experience of case load management.
- -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.
- -You are a person who is willing to go the extra mile for a person to ensure they get the right care and support. You are passionate about making a difference to peoples lives
- -You possess a strong and practical understanding of safeguarding policy and practice and are up to date with current legislation.
- -Excellent communication and interpersonal skills.
- -Experience of working in teams.
- -Experience of collaborative working.
- -Knowledge and understanding of equality and diversity.
- -Knowledge and understanding of GDPR.
- -You can plan, prioritise and carry out your work in a flexible way. You are accustomed to working on your own and in teams.
- -Adaptability, flexibility and ability to cope with uncertainty and change.
- -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.
- -Excellent time keeping and prioritisation skills.
- -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.
- -Access to own transport and ability to travel across the PCN locality on a regular basis
Desirable
- -Experience of working within the community, voluntary and/or primary care.
- -Flexibility to work outside of core office hours
- -Disclosure Barring Service (DBS) check
- -Experience of providing social prescribing interventions
- -Knowledge of health and social care
- -Local knowledge of the voluntary and community sector
- -Ability to use Microsoft 365
- -Specific Aptitudes Awareness of equality and valuing diversity principles Understanding of Confidentiality and Data Protection Act
- -Self-motivated and proactive
- -Continued commitment to improve skills and ability in new areas of work
- -Able to undertake the demands of the post with reasonable adjustments if required
- -Ability to work from home on some occasions where tasks allow
Person Specification
Qualifications
Essential
- Essential Qualifications
- -No formal qualifications are required but you must have high emotional intelligence and resilience, be a win-win negotiator, and be brave enough to change the culture around high-intensity use of services.
- -The candidate needs to shine and connect well in interviews to demonstrate these skills.
- -Motivational interviewing
- -Coaching for Health and Wellbeing
- -Personalised Care Institute e-learning modules, PCSP, shared decision making or equivalent.
Experience
Essential
- -Experience of supporting vulnerable adults in a person-centred way.
- -Experience of working in the voluntary and community sector.
- -You have the ability to work sensitively in difficult emotional circumstances with empathy, compassion, respect and understanding.
- -Knowledge of asset/strength-based recovery models and approaches
- -Experience of case load management.
- -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.
- -You are a person who is willing to go the extra mile for a person to ensure they get the right care and support. You are passionate about making a difference to peoples lives
- -You possess a strong and practical understanding of safeguarding policy and practice and are up to date with current legislation.
- -Excellent communication and interpersonal skills.
- -Experience of working in teams.
- -Experience of collaborative working.
- -Knowledge and understanding of equality and diversity.
- -Knowledge and understanding of GDPR.
- -You can plan, prioritise and carry out your work in a flexible way. You are accustomed to working on your own and in teams.
- -Adaptability, flexibility and ability to cope with uncertainty and change.
- -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.
- -Excellent time keeping and prioritisation skills.
- -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.
- -Access to own transport and ability to travel across the PCN locality on a regular basis
Desirable
- -Experience of working within the community, voluntary and/or primary care.
- -Flexibility to work outside of core office hours
- -Disclosure Barring Service (DBS) check
- -Experience of providing social prescribing interventions
- -Knowledge of health and social care
- -Local knowledge of the voluntary and community sector
- -Ability to use Microsoft 365
- -Specific Aptitudes Awareness of equality and valuing diversity principles Understanding of Confidentiality and Data Protection Act
- -Self-motivated and proactive
- -Continued commitment to improve skills and ability in new areas of work
- -Able to undertake the demands of the post with reasonable adjustments if required
- -Ability to work from home on some occasions where tasks allow
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.
