Job summary
The IntegratedNeighbourhood Team Coordinator plays a vital role in facilitating all Communitybased activities within health and social care. They are non-clinical staffmembers, who work closely alongside existing services including health, socialcare and Voluntary, Community and Social Enterprise (VCSE) organisations.
TheCoordinators are the glue that holds together the collaborative working of theother services, acting as point of liaison between the partners that make upthe Neighbourhood Teams. The role of the Coordinators exists to ensure that thebenefits of integrated working are maximised, while also making it as easy aspossible for a member of the public to navigate.
There are seven whole time equivalents roles ( hours) to cover the whole of our Wakefield District. Six of the roles will be based across the district in Community Hubs and one role will be in the Acute Trust.
Main duties of the job
The day-to-day role of the Integrated Neighbourhood Team Coordinator can be split into three areas:
1. Supporting the integrated working of health and social care with shared team of system partners convening MDT panels
2. Becoming a local expert (one amongst many in the community) understanding the strengths and challenges of the Neighbourhood
3. Holding a caseload of people who they directly support to navigate the health and care system and access local groups and services
About us
We provide care and support to over a million people inWakefield and Kirklees in their homes, community settings and across ourthree hospital sites at Pontefract, Dewsbury and Pinderfields (Wakefield).
Always striving for excellence, we are at the forefront ofinnovation and research, and we invest in teaching and the development of ourworkforce.
We live by our values of caring, improving, being respectfuland maintaining high standards. We listen and learn because we aim to make MidYorkshire the best place to work and receive care.
We value diversity and welcome talent and enthusiasmirrespective of age, disability, neurodivergence, sex, gender identity andgender expression, race or ethnicity, religion or belief, sexual orientation,or other personal circumstances including providing unpaid carers support tosomeone with a health and care need. As ethnic minority groups, members of theLGBTQ+ community, and people with a disability/neurodivergence are currentlyunder-represented across the organisation, we encourage applications frommembers of these groups. We have policies and procedures to ensure allapplicants are treated fairly and consistently.
We are proud of our staff networks - who offer valuableguidance and feedback from those with lived experience.
We have a clear vision and you could be part of this! Ifyou share our values and you want to make a difference to the lives of ourpatients and their families and carers, we would love to hear from you.
Job description
Job responsibilities
4. Proactively coordinatingservices across boundaries to ensure people are kept in the community throughreducing the need for formal health and social care provision
5. Facilitate and coordinate anintegrated health and social care approach within Neighbourhood Teams, includingproviding administrative support for/ chairing MDT meetings for services
6. Take ownership of the NeighbourhoodTeams Anticipatory Care cohort, ensuring that:
7. A personalised care plan isin place for each individual
8. Responsibility to maintainand keep up to date records of individuals identified as being part of thecohort care treatment and advice
9. The Neighborhood Team hasaccess to the appropriate services and expertise to support their AnticipatoryCare cohorts. Escalating any issues to the appropriate channels.
10. Make contact and buildrelationships with a wide range of local community and voluntary sectororganisations in order to effectively signpost people to these organisations asthe need arises
11. Identify gaps in communityprovision and escalate identified gaps to the appropriate channels
12. To champion and coordinate apersonalised case management approach by accessing multiple services to ensure appropriatecare packages are in place
13. Dealing with highly complexpersonalised care packages. Assessment of care needs with clinicians todetermine the appropriate health and social care support
14. Gather information andintelligence at the earliest opportunity and present this to clinicians to givethem confidence and aid their decisions are helping prevent any unnecessaryadmissions to hospital
15. Promote access to relevantservices and cascade information that aids the support of person discharge as well as following thisup in the community by either a phone call or face to face visit
16. Link people directly intorelevant health, social and VCSE services as well as signposting and linkingpeople into services to support them in the community
17. Provide people with choiceand ensure people and their carers have access to the most appropriate servicesat the right time in the right place
18. Monitor people and workwith services to reduce the risk of deterioration and help prevent unnecessaryhospital admissions
19. Support the role of the keyworker in the community and implement a monitored support plan
20. To make recommendations regarding referrals, using triage protocols toensure that people are seen by the most appropriate team / service at the righttime to meet their needs. Whilst recognising the need to involve, or seekadvice from, more experienced colleagues as necessary when the decision is of aclinical nature
21. Responsible for the coordination and to liaise with all relevantstatutory and VCSE sector services including the local authority responsiblefor a persons care to arrange the necessary support
22. Responsible for tracking people through the health and social caresystem to ensure a smooth hand over to a named care manager / service
23. Contribute to the integration of health and social care by maintainingup to date recording systems for all agencies within the neighbourhood team
24. Responsible for providing information to any member of the neighbourhoodteam in order to ease processes and communication in agreement with dataprotection protocol
25. Responsible for providing information to support overall Integrated careprogramme evaluation
26. To record and maintain people interventions on relevant systems (EMIS, EPR and Liquid Logic amongst others) and contribute to report generationand analysis from the data
27. To be customer focused when representing the service and ensuring thatthe reception people are given is supportive, welcoming and helpful
28. To work within the relevant legal frameworks and have an understandingof the Data Protection Act and how this relates to the management of confidentialinformation in accordance with health and social care policy.
29. To independently plan and organise own work using own initiative, whilstbeing able to work as a valuable member of a team
30. Able to manage own diary and workload autonomously
31. Assist in the orientation and local inductions of new starters
32. To undertake general administrative duties to support the role
33. To participate in individual appraisal and supervision, contributing tothe identification of training opportunities
34. To work effectively as part of a team and to provide cover when requiredand to be flexible regarding working hours to meet the needs of the service
35. To undertake supervisory responsibilities including supervision andProfessional Development Reviews
36. To use effective communication skills when liaising with professionalsand members of the public over the telephone or in person
37. To liaise with a range of professionals within community and hospitalsettings, including VCSE organisations.
38. Visit service users either in a hospital in-patient setting, in thepersons home environment or GP practice to gather initial information and tofollow up to assess progress on intervention
39. To work autonomously as well as part of ateam, this will require lone working in both hospital and community settlingsincluding service users home environments. Toreceive and deliver complex, sensitiveor contentious information, where persuasive skills are required in discussingmedical intervention plans.
Person Specification
Skills and Abilities
Essential
40. To make independent decisions based using a range of facts and situations that require analysis
41. Well established verbal and written communication skills with team/clients/relatives
42. Ability to deal with highly distressing/sensitive information Advanced Care Planning for end of life patients
43. Ability to deal with health and social care conflict in community environment, using tact and persuasive skills
44. Demonstrate a caring manner with an understanding of how to deal with challenging behaviours
45. Driving Licence with access to car
46. Highly organised, able to work to strict deadlines and ensure quality standards are met
47. Ability to engage and motivate others and self
48. Flexibility and able to adapt to change
49. Proven ability of working on own initiative
50. Able to work as part of a team
51. Able to prioritise workload
52. Ability to establish effective working relationships
53. Planning and organising a range of complex activities
Desirable
54. Ability to deal with irate and worried people accessing the service
55. Time management skills or experience of working with a busy/demanding environment
56. Supervisory or office management skills
Qualifications
Essential
57. NVQ Level 3 qualification in a health or social care setting or equivalent level/experience
58. 4 GCSEs, grade C or above
Desirable
59. NVQ Level 4 qualification in a health or social care setting or equivalent level/experience
Experience
Essential
60. Experience of scheduling/co-ordination activities and/or resources such as care planning
61. Experience of working with confidential material working on SystmOne
62. Experience of working within a Multi-disciplinary team (MDT) setting
63. Experience of building effective working relationships
64. Experience of working within a Community /Neighbourhood setting and or interest specialist groups Cardiac/Diabetes
65. Well-developed experience working in patient or customer care setting
66. Experience of working with computer software programmes such as Microsoft Office, e-mail and internet
Desirable
67. Experience of working with patients requiring health or social care
68. Experience with NHS software systems
69. Experience of working within General Practice or hospital environment
70. Experience of local needs assessment within communities
71. Experience of monitoring and evaluating care plans
72. Experience of writing reports and case studies
Knowledge and Awareness
Essential
73. An understanding of health and social care issues for vulnerable adults and how these relate to health inequalities
74. An understanding of the principles of Multidisciplinary Team (MDT) working
75. Sensitive to confidential environment
76. Understanding and knowledge of work policies and procedures (Data Protection Act)
77. Awareness of own limitations.
Desirable
78. Understanding of NHS Confidentiality issues
79. Awareness of Health & Safety issues
80. Awareness of Moving & Handling issues.
81. Understanding and knowledge of work policies and procedures (Caldicott)
82. Knowledge of medical terminology
83. A sound knowledge of principles and practice of health and wellbeing and preventive approaches
84. Knowledge of Primary Care Networks and non-clinical roles
85. Knowledge of local voluntary and community, and statutory services relating to vulnerable adults
86. Knowledge of Trust/Patient Access Policy/Medical Records Policies