Job summary
The post-holder will be joining the Whole System Integrated Team (WSIC) at K&W Healthcare Ltd and will be providing case management and care planning to patients with long term conditions to improve their health outcomes and reduce the risk of hospital admissions and demand on secondary care.
Main duties of the job
Duties may be
varied from time to time under the direction of the Project Manager,
dependent on current and evolving workload and staffing levels:
Set up and service the weekly CPMG
meetings.
Document referrals, assemble any
relevant paperwork and draw up a list of patients prior to the CPMG meeting.
Ensure that the actions set out
following CPMG meetings are followed up and that actions from different
professionals are coordinated around individual personal needs.
Be a direct point of contact to the
patient, carer or service user and the CPMG team.
Following the discharge of
persons from the CPMG, carry out further actions to monitor their progress, as
directed by the CPMG team.
About us
K&W Healthcares primary objective is to support GP Practices and services across the Brent localities of Kingsbury, Willesden and Wembley.Ouraim isto develop quality primary care for patients within Brent and strive for continuous improvement in the delivery of primary healthcare services across our GP practices.
K&W Healthcare is a GP-led organisation made up of 27 GP practices serving a registered population of over 220,000 patients. We are committed to improving the care provided to patients, reducing health inequalities and raising the quality and standards of GP practices.
You can find out more about our governing body, member practices and how we work with Brent Integrated Care Partnership to provide better outcomes for our patients by clicking the button below.
Job description
Job responsibilities
Support the CPMG team and General Practices in the identification of appropriate patients for care planning and case management. Liaise with a range of health and social care providers including primary, community, social,third sector and secondary care to collate the necessary information about the patients forcare planning and case management. Support patients and their nominated relatives through the care planning and case management process. Provide administrative, communication and performance management support at individual GP Practices as well as within the CPMG team. Be able to plan, organise and have good time management skills to prioritise their own workload. Work with a list of named patients with the aim of encouraging independence, alongside the GP and CPMG team, enabling people to remain at home. Reducing unnecessary admissions tohospital or attendance at A & E and supporting timely discharge from the Virtual ward. Provide feedback to the Practice and CPMG team, troubleshoot and escalate actions as necessary. Facilitate and ensure the effective delivery of patient-centred, personalised health and social care for patients, monitoring progress and reporting outcomes to the GP, Senior Nurse Case Manager and the CPMG team. Contribute to patient reviews and care planning within appropriate time frames. Liaise between services and service users, contacting services using the appropriate procedures. Facilitate effective delivery of patient-centred, personalised health and social care for patients, by monitoring progress and reporting outcomes. Ensure personalised care plans remain up to date and that they are evaluated and revised as necessary. Ensure contact is made with each person 'accepted' onto the CPMG and the proposed plan of care is communicated following liaison with the Senior Nurse Case Manager.
Job description
Job responsibilities
Support the CPMG team and General Practices in the identification of appropriate patients for care planning and case management. Liaise with a range of health and social care providers including primary, community, social,third sector and secondary care to collate the necessary information about the patients forcare planning and case management. Support patients and their nominated relatives through the care planning and case management process. Provide administrative, communication and performance management support at individual GP Practices as well as within the CPMG team. Be able to plan, organise and have good time management skills to prioritise their own workload. Work with a list of named patients with the aim of encouraging independence, alongside the GP and CPMG team, enabling people to remain at home. Reducing unnecessary admissions tohospital or attendance at A & E and supporting timely discharge from the Virtual ward. Provide feedback to the Practice and CPMG team, troubleshoot and escalate actions as necessary. Facilitate and ensure the effective delivery of patient-centred, personalised health and social care for patients, monitoring progress and reporting outcomes to the GP, Senior Nurse Case Manager and the CPMG team. Contribute to patient reviews and care planning within appropriate time frames. Liaise between services and service users, contacting services using the appropriate procedures. Facilitate effective delivery of patient-centred, personalised health and social care for patients, by monitoring progress and reporting outcomes. Ensure personalised care plans remain up to date and that they are evaluated and revised as necessary. Ensure contact is made with each person 'accepted' onto the CPMG and the proposed plan of care is communicated following liaison with the Senior Nurse Case Manager.
Person Specification
Qualifications
Essential
- Health and Social Care Level 2 or 3
Person Specification
Qualifications
Essential
- Health and Social Care Level 2 or 3
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.