Job summary
Mon - Fri 9-5
The Case Manager will work within an integrated neighbourhood/care team (ICT/INT) to proactively undertake case finding, manage, co-ordinate and support patients with multiple complex long-term conditions using the whole systems integrated care (WSICS) dashboards, with responsibility for ensuring all health and social care needs are met for risk stratification and managing frailty patient populations registered in the Primary Care Networks (PCNs) aligned to the ICT/INT. The post holder will also support the health inequalities agenda through engagement of patients in the most deprived areas of the West London borough and work with key stakeholders on the wider determinants of health to improve outcomes, functional status and quality of life, ensuring integration of all elements of care, increase patient choice and prevent unnecessary admissions to hospital and reduce the stay of necessary hospital admissions.
Main duties of the job
o he post holder will work as a minimum, 80% of their time in direct patient care. This will be spent supporting caseload allocation, providing practice development and education and competence support to the Case Managers and Health and Social Prescribing Coordinators
o Work with the Primary Care Networks in the identification of those patients at high risk for acute hospital admission and ensure those identified are assessed and have care planned appropriately to reduce their risk of admission.
o Empower patients and carers through appropriate support and education, ensure care provided and service delivered are in line with National Service Framework, NICE Guidelines, Trust policies and procedures and the Clinical Governance Framework.
o Work with Community Practitioners on the promotion of patient self-management programmes within the local community.
o Have clinical responsibility for practice caseloads including aspects of care delivery and co-ordination in line with service operating procedures.
o Support safer caseloads across the ICT/INT minimising service risk in relation to workflow and productivity responding to referrals in a timely manner, acting swiftly to address waiting time portal breaches.
About us
We providecommunity health services to more than two million people across eleven London boroughs and Hertfordshire.
Every day, our professionals provide high-quality healthcare in people's homes and local clinics, helping them to:
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stay well
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manage their own health with the right support
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avoid unnecessary trips to, or long stays in, hospital.
We support our patients at every stage of their lives, providing health visiting for new-born babies through to community nursing, stroke rehabilitation and palliative care for people towards the end of their lives.
Our vision:deliver great care closer to home.
Our mission: working together to give children a better start and adults greater independence
Job description
Job responsibilities
Operational support and management for the Case Managers and Health and Social Prescribing Co-ordinators
Working with other Case Managers providing cover for GP practices during periods of absence and leave ensuring there is service cover and clear escalation processes for practice teams to contact.
Leading and developing others through role modelling improved and evidence-based practice.
Providing supportive and facilitative clinical leadership in ICT/INT forums.
Manage the day to day, ongoing delivery and development of the service that is responsive, high quality, value for money, and meets service specifications.
Responsible for service delivery metrics, monitoring of performance activity reports i.e. referrals, hub/home visits, care plans, outcomes, and utilisation.
Job description
Job responsibilities
Operational support and management for the Case Managers and Health and Social Prescribing Co-ordinators
Working with other Case Managers providing cover for GP practices during periods of absence and leave ensuring there is service cover and clear escalation processes for practice teams to contact.
Leading and developing others through role modelling improved and evidence-based practice.
Providing supportive and facilitative clinical leadership in ICT/INT forums.
Manage the day to day, ongoing delivery and development of the service that is responsive, high quality, value for money, and meets service specifications.
Responsible for service delivery metrics, monitoring of performance activity reports i.e. referrals, hub/home visits, care plans, outcomes, and utilisation.
Person Specification
Education/Qualification
Essential
- Registered Adult/Mental Health Nurse
- Educated to Degree/Masters level or equivalent postgraduate experience
- Clinical Supervision Training
- Teaching and Mentoring
Desirable
- Dual Registered Nurse
- V300 Non-Medical Prescriber
- Advance Clinical Practitioner or willing to undertake
Experience
Essential
- Extensive work experience at a Band 7 or above in a community/hospital/primary care setting
- Experience of presenting cases at large multi-disciplinary teams,
- Experience of Frailty Populations, Long Term Conditions, Palliative Care, Respiratory, Cardiovascular Disease, Dementia
- Experience of working with stakeholders and collaborative negotiating, advocating for patients
Desirable
- Experience of managing and investigating complaints
- Experience of managing and investigating serious incidents.
Skills & Knowledge
Essential
- Line management of clinical staff in line with trust HR Process.
- Goal setting with patients, coaching techniques to self-care and empowerment.
- Knowledge of CHC, Fast track EoL Assessments
Person Specification
Education/Qualification
Essential
- Registered Adult/Mental Health Nurse
- Educated to Degree/Masters level or equivalent postgraduate experience
- Clinical Supervision Training
- Teaching and Mentoring
Desirable
- Dual Registered Nurse
- V300 Non-Medical Prescriber
- Advance Clinical Practitioner or willing to undertake
Experience
Essential
- Extensive work experience at a Band 7 or above in a community/hospital/primary care setting
- Experience of presenting cases at large multi-disciplinary teams,
- Experience of Frailty Populations, Long Term Conditions, Palliative Care, Respiratory, Cardiovascular Disease, Dementia
- Experience of working with stakeholders and collaborative negotiating, advocating for patients
Desirable
- Experience of managing and investigating complaints
- Experience of managing and investigating serious incidents.
Skills & Knowledge
Essential
- Line management of clinical staff in line with trust HR Process.
- Goal setting with patients, coaching techniques to self-care and empowerment.
- Knowledge of CHC, Fast track EoL Assessments
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).
Employer details
Employer name
Central London Community Health Trust
Address
St Charles Hospital Exmoor Street / Golborne Medical Centre
London
W10 6DZ
Employer's website
https://clch.nhs.uk/ (Opens in a new tab)
