Integrated Neighbourhood Team (INT) Caseworker

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 using e.g. EMIS Web, Microsoft Excel, AccuRx and Healthintent.
• Manage and maintain the INT caseload, ensuring efficient prioritisation and monitoring of patient progress.
• Collaborate with multidisciplinary teams to coordinate and manage patient support plans.

Holistic Patient Assessments

• Conduct holistic face to face assessments with patients to understand their health, social care, and personal support needs.
• Conducting blood pressure, weight, height and pulse check
• Conducting blood tests if needed training can be provided
• Work with patients to set achievable goals and identify solutions that promote independence and well-being.
• Use an evidence-based approach to recognise patient priorities and encourage self-management wherever possible.
• Facilitate group consultations for long term conditions including Diabetes, Atrial Fibrillation, Chronic Kidney Disease and Hypertension.
• 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.
• Manage INT PCN email inbox using Microsoft Outlook
• 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

INT Clinical Lead Pharmacists

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.

Mobility

The post-holder may be required to work at any appropriate site within the neighbourhood as necessary for the delivery of the functions of this role.

Equality & Diversity

Staff have the right to be treated fairly in recruitment and career progression. Staff can expect to work in an environment where diversity is valued, and equality of opportunity is promoted.

Staff will not be discriminated against on any grounds including age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation.

Staff have a responsibility to ensure that they treat their colleagues and others they may interact with dignity and respect.

Health & Safety

Employees must be aware of the responsibility placed on them under the Health and Safety at Work Act (1974) to maintain a healthy and safe working environment for both staff and visitors.

Data Protection

All the personal information we hold, obtain, record, use and share as an organisation is governed under the Data Protection Act 2018/General Data Protection Regulations.

You have a legal responsibility for all personal information you handle and must not at any time use the personal data in a way incompatible with the guidelines stipulated in this act.

If you are in any doubt regarding what you should or should not do in connection with the Data Protection Act and the General Data Protection Regulations, then you must contact your Line Manager

RecordsManagement

You have a legal responsibility for all records you work with e.g. Patient records, financial records, personal, administrative, etc that you gather or use as part of your work.

The records may be held in a variety of formats such as paper, electronic, microfiche, audio, and video tapes, etc.You must consult your manager if you have any doubt as to the correct management of the records with which you work.

Confidentiality

In the course of your employment, you will have access to confidential information.You are required to exercise due consideration in the way you use such information and should not act in any way, which might be prejudicial to the organisations interests.

If you are in any doubt regarding the use of information in the pursuit of your duties, you should seek advice from your Line Manager before communicating such information to any third party.

Any inappropriate disclosure may be subject to disciplinary procedures.

Infection Control

All staff are responsible for protecting themselves and others against infection risks. All staff regardless of whether clinical or not are expected to comply with current infection control policies and procedures and to report any problems regarding this to their managers

Person Specification

Qualifications

Essential

• Good general education with English and Maths to GCSE standard or equivalent
• Relevant NVQ 3 or equivalent qualification or experience.

Desirable

• Competence in completing phlebotomy

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 including EMIS Web, Microsoft Excel/Word/Outlook and AccuRx
• Problem-solving skills to address various challenges
• Able to travel between practice sites The Vale Medical Centre, Sydenham Green Group Practice, Wells Park Practice, Woolstone Medical Centre and additional community centres or venues across Lewisham Borough

Desirable

• Can speak multiple languages

Experience

Essential

• Previous experience in health, social care, or community coordination roles
• Familiarity with face to face holistic assessment approaches and patient-centred care planning
• Understanding of population health management and tackling health inequalities
• Competence in completing NHS Health Checks and Diabetes 8 Care Processes including blood pressure, weight, height and pulse checks

Desirable

• Competence in completing phlebotomy
• Knowledge of the Lewisham area and its health and care landscape
• Experience with working with those with Learning Disabilities and SMI

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.

Employer details

Employer name

Aplos Health PCN

Address

Woolstone Medical Centre

Woolstone Road

London

SE23 2SG

Employer's website

https://www.aploshealth.co.uk/ (Opens in a new tab)