Job summary
***Important Sponsorship Information for this post: We are currently unable to offer a certificate of sponsorship for this post***
Our 'Home First' vision is for Greenwich residents to receive the highest quality of care in the safest environment and wherever possible this will be their home.
An exciting opportunity in the Adult Community Physical Health Services directorate has arisen for an Integrated Complex Case Manager for Care Homes in Greenwich. This is a positive time to join us as we embark on a range of transformation projects within our services. Our 'Home First' and Virtual Ward programmes are well established and have supported keeping patients at home instead of being admitted to hospital. The successful applicant will be a crucial part of our model within Care Homes to support care in the community and promote health and wellbeing for residents of care homes in Greenwich.
Main duties of the job
The Integrated Complex Case Manager for Care homes in Greenwich utilises an MDT approach under the Enhanced health in Care homes framework. The postholder will work closely with Primary care, community-based services, Care Home Managers and, Social Care teams to support effective interventions for our Care Home residents. The aim of the role is to reduce hospital admissions and maintain a high standard of care in the community.
The service sits within an integrated organisation model between Greenwich community physical health services and the Royal Borough of Greenwich. The Multidisciplinary Teams provide care management and rehabilitation, and include Social Workers, Care Managers, Dieticians, Physiotherapists, Podiatrists, Occupational Therapists, and Speech and Language Therapists.
- Have a good understanding of working with complex health issues and particularly elderly frail patients residing in Care Homes
- Able to build good relationships with key stakeholders and the MDT and communicate effectively.
- Have experience of working with an MDT and be able to lead staff of different disciplines, working collaboratively with medical colleagues.
- Work closely with key stakeholders in South East London.
- Work as part of the Greenwich Home First and Virtual Ward programmes to develop care closer to home and support early hospital discharge.
About us
Oxleas offers a wide range of NHS healthcare services to people in community and secure environment settings. Our services include community health care such as district nursing and speech and language therapy, care for people with learning disabilities and mental health care such as psychiatry, nursing and therapies. Our multidisciplinary teams look after people of all ages and we work in close partnership with other parts of the NHS, local councils and the voluntary sector and through our new provider collaboratives. Our 4,300 members of staff work in many different settings including hospitals, clinics, prisons, secure hospitals, children's centres, schools and people's homes.We have over 125 sites in a variety of locations in the South of England. In London we operate within the Boroughs of Bexley, Bromley Greenwich and into Kent. We manage hospital sites including Queen Mary's Hospital, Sidcup and Memorial Hospital, Woolwich, as well as the Bracton Centre, our medium secure unit for people with mental health needs. We are the largest NHS provider of prison health services providing healthcare to prisons within Devon, Dorset, Bristol, Wiltshire and Gloucestershire, Kent and South London. We are proud of the care we provide and our people.
Our purpose is to improve lives by providing the best possible care to our patients and their families. This is strengthened by our new values:
- We're Kind
- We're Fair
- We Listen
- We Care
Job description
Job responsibilities
- To lead on and support the on-going delivery of a robust and resilient Enhanced Health in Care Homes Model in Greenwich by organising regular virtual Multi-Disciplinary Team (MDT) reviews of individuals discussed at a monthly MDT.
- To lead on MDT meetings and support colleagues to develop universal care plans within the MDT and be able to support delivery in Care Homes.
- Skilled in care of the older person, including Complex Geriatric Assessment, with awareness of challenges specific to this patient cohort and care and support required in care homes.
- To be responsible for leading and monitoring the outcomes of regular meetings including the performance improvement action plans with agreed partners.
- To lead and coordinate the MDTs with partners for an agreed cohort of individuals who are Care Home residents with multiple Health needs or are high intensity users of A& E with multiple presentations.
- Working with the MDT including GPs and acute hospital including consultants and other key system partners in identification of frequent attenders and production of Advance Management Plans.
- Develop and implement a regular contact mechanism for GPs, LAS and other service providers to flag up high impact users to prevent hospital admissions.
- Organising and chairing the virtual MDT meetings, ensuring attendance and engagement of key players.
- Profiling and highlighting agreed MDT outcomes, ensuring action is taken for the cohort of individuals identified including robust plans of care, anticipatory care planning is in place.
- Attend ICM meetings and ensure consistent system communication regarding identified cohort of patients and that actions are followed up and completed.
- To ensure collaborative working is undertaken across Greenwich with regards to frequent attenders/ high impact users/multiple emergency spells.
- Developing system/data base of this cohort of patients. Utilising and analysing this to develop and implement a more robust model within Greenwich for the overall identification and management for this cohort of patients.
- Analysis and interpretation of performance information to actively contribute to capacity planning and review processes and link to the Frailty PCN Model.
- Responsible to ensure the model extends across the whole system for the borough of Greenwich Care Home patients this includes RBG, primary care, Community services, third sector/voluntary sector, care homes and all acute sites.
- To be able to evaluate the role and develop strategies to support improved health care in care homes.
Job description
Job responsibilities
- To lead on and support the on-going delivery of a robust and resilient Enhanced Health in Care Homes Model in Greenwich by organising regular virtual Multi-Disciplinary Team (MDT) reviews of individuals discussed at a monthly MDT.
- To lead on MDT meetings and support colleagues to develop universal care plans within the MDT and be able to support delivery in Care Homes.
- Skilled in care of the older person, including Complex Geriatric Assessment, with awareness of challenges specific to this patient cohort and care and support required in care homes.
- To be responsible for leading and monitoring the outcomes of regular meetings including the performance improvement action plans with agreed partners.
- To lead and coordinate the MDTs with partners for an agreed cohort of individuals who are Care Home residents with multiple Health needs or are high intensity users of A& E with multiple presentations.
- Working with the MDT including GPs and acute hospital including consultants and other key system partners in identification of frequent attenders and production of Advance Management Plans.
- Develop and implement a regular contact mechanism for GPs, LAS and other service providers to flag up high impact users to prevent hospital admissions.
- Organising and chairing the virtual MDT meetings, ensuring attendance and engagement of key players.
- Profiling and highlighting agreed MDT outcomes, ensuring action is taken for the cohort of individuals identified including robust plans of care, anticipatory care planning is in place.
- Attend ICM meetings and ensure consistent system communication regarding identified cohort of patients and that actions are followed up and completed.
- To ensure collaborative working is undertaken across Greenwich with regards to frequent attenders/ high impact users/multiple emergency spells.
- Developing system/data base of this cohort of patients. Utilising and analysing this to develop and implement a more robust model within Greenwich for the overall identification and management for this cohort of patients.
- Analysis and interpretation of performance information to actively contribute to capacity planning and review processes and link to the Frailty PCN Model.
- Responsible to ensure the model extends across the whole system for the borough of Greenwich Care Home patients this includes RBG, primary care, Community services, third sector/voluntary sector, care homes and all acute sites.
- To be able to evaluate the role and develop strategies to support improved health care in care homes.
Person Specification
Experience of chairing MDTs
Essential
- Able to evidence awareness and experience of successful MDT chairing in previous roles
Experience of working with care home residents
Essential
- evidences awareness of the complexities of this client group
Registration with HCPC or NMC
Essential
- at least 5 years at a senior level
able to network and build partner relationships
Essential
- evidence of partnership working
Person Specification
Experience of chairing MDTs
Essential
- Able to evidence awareness and experience of successful MDT chairing in previous roles
Experience of working with care home residents
Essential
- evidences awareness of the complexities of this client group
Registration with HCPC or NMC
Essential
- at least 5 years at a senior level
able to network and build partner relationships
Essential
- evidence of partnership working
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.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
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.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
