Job summary
This post is offered to support existing Practice Care Coordinator colleagues in St JohnsMedical Practice in Grantham to increase capacity to support people in their own homes and within care home settings.
The role will be employed within K2 Healthcare and based within the Grantham
Neighbourhood Hub, hours of work to be negotiated at interview, but full and part time
options will be considered.
Main duties of the job
An exciting opportunity to improve our capacity and capability to deliver more proactive,
high quality and safe care.
The role of the Practice Care Co-ordinator is to lead and support Primary Care Network colleagues and members of the integrated neighbourhood workforce to identify individuals and reduce the risk of unplanned hospital admissions and to effectively support those individuals in the community. To work dedicated hours to focus on proactively case managing people and being the preferred point of contact for the patient and Neighbourhood Team in order to achieve the following objectives: To be a pro-active member of the Neighbourhood Team To pro-actively engage with people deemed to be at a high risk of hospital admission To pro-actively engage with home first teams to reduce length of stay in hospital To pro-actively engage with Care Homes within the locality. To pro-actively engage with housebound people and their carers To be a key contact for people at the GP Practice You must have First Level Registration NMC or equivalent professional qualification and registration. Able to demonstrated post graduate study in health related studies relevant to long term conditions or equivalent experience, evidence of continuing professional development. You will also have excellent interpersonal and communication skills, be highly motivated and positive in your approach to care delivery to ensure we maintain a high quality service delivery to our population.
About us
K2 Healthcare is a GP federation constituted of 16 member GP Practices in South West Lincolnshire with two Primary Care Networks and supporting a population of 133,000 people.
K2 works together to share resources and expertise that enable practices to provide shared services and business systems to provide the best possible care for our population, ensure sustainability, growth and value for GP practices and system partners within available resources.
The Better Lives Lincolnshire Integrated Care System sees us working in a provider collaborative with the Primary Care Network Alliance, Secondary Care, Community Health, Mental Health, Social Care as well as Local Authorities, and the Community and Voluntary Sector.
How we do it is as important as what we do and relationships with our partners is at the core of everything we do.
Neighbourhood Working describes an integrated approach to managing patients, through a blended workforce that encompasses both health and social care; to include acute, voluntary and community sectors where barriers to working are negated, the health and wellbeing needs of the individual are at the centre of decision-making, care is proactive and not reactive, and services are provided in a timely manner.
Job description
Job responsibilities
To progress integrated and neighbourhood working alongside the development of primary care networks.
Neighbourhood working has been developed to provide a collaborative approach to delivering local
services and joined up support for people locally. This includes involvement from health, social care, local
authority, third sector and voluntary and community organisations; everyone working together to find solutions to the health and wellbeing challenges in Lincolnshire. Neighbourhood working is about working together with each individual person, to identify who and what matters to them, and recognising in partnership what could be done to help keep local people safe, well and happy in their own homes.
This Role is designed to:
*Provide advanced clinical care using high level assessment to make a diagnosis, initiate / prescribe medical / nursing treatments, refer appropriately and co-ordinate the patients journey across the health, social care and voluntary sector system, regardless of care setting
*Perform comprehensive geriatric assessment (CGA) and work toward strength-based care
*To work as an accountable and autonomous practitioner working to pro-actively monitor and anticipate changing phase of illness and health and social care needs of patients with long term conditions (LTCs) and / or complex long or short-term care needs
*To ensure delivery of a person-centred approach, what matters to me to all patients that enables individuals to achieve their optimum physical, psychological and social well being
*To provide a timely response to referrals and be responsible for advanced clinical care using comprehensive, evidence based, holistic assessment promoting high quality standards and cost effectiveness in all aspects of care delivery.
*To be responsible for effective feedback from all members of the neighbourhood and integrated working teams
*To be the designated clinician for named GP practices in a geographical area and be responsible for maintaining comprehensive clinical communication with general practices and neighbourhood colleagues, providing timely feedback to the service manager
*Improve clinical outcomes for patients by enabling them to function independently by increasing their choice to remain in their own home / community and reduce the need for, or prevent inappropriate hospital admission
*Identification of high intensity users with needs using risk stratification systems and other sources of information
The post holder will work within the context of local and national drivers and ICB plan.
Job description
Job responsibilities
To progress integrated and neighbourhood working alongside the development of primary care networks.
Neighbourhood working has been developed to provide a collaborative approach to delivering local
services and joined up support for people locally. This includes involvement from health, social care, local
authority, third sector and voluntary and community organisations; everyone working together to find solutions to the health and wellbeing challenges in Lincolnshire. Neighbourhood working is about working together with each individual person, to identify who and what matters to them, and recognising in partnership what could be done to help keep local people safe, well and happy in their own homes.
This Role is designed to:
*Provide advanced clinical care using high level assessment to make a diagnosis, initiate / prescribe medical / nursing treatments, refer appropriately and co-ordinate the patients journey across the health, social care and voluntary sector system, regardless of care setting
*Perform comprehensive geriatric assessment (CGA) and work toward strength-based care
*To work as an accountable and autonomous practitioner working to pro-actively monitor and anticipate changing phase of illness and health and social care needs of patients with long term conditions (LTCs) and / or complex long or short-term care needs
*To ensure delivery of a person-centred approach, what matters to me to all patients that enables individuals to achieve their optimum physical, psychological and social well being
*To provide a timely response to referrals and be responsible for advanced clinical care using comprehensive, evidence based, holistic assessment promoting high quality standards and cost effectiveness in all aspects of care delivery.
*To be responsible for effective feedback from all members of the neighbourhood and integrated working teams
*To be the designated clinician for named GP practices in a geographical area and be responsible for maintaining comprehensive clinical communication with general practices and neighbourhood colleagues, providing timely feedback to the service manager
*Improve clinical outcomes for patients by enabling them to function independently by increasing their choice to remain in their own home / community and reduce the need for, or prevent inappropriate hospital admission
*Identification of high intensity users with needs using risk stratification systems and other sources of information
The post holder will work within the context of local and national drivers and ICB plan.
Person Specification
Qualifications
Essential
- See attached Job Description document.
Desirable
- See attached Job Description document.
Experience
Essential
- See attached Job Description document.
Desirable
- See attached Job Description document.
Person Specification
Qualifications
Essential
- See attached Job Description document.
Desirable
- See attached Job Description document.
Experience
Essential
- See attached Job Description document.
Desirable
- See attached Job Description document.
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
Additional information
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
