Are you passionate about patient care and want to make a difference to patients by navigating them through health & social systems
We are seeking to recruit 1 WTE Care Navigator for Bassetlaw. The role of Care Navigator is new to Bassetlaw; its a great opportunity for someone who is enthusiastic & passionate about patient care.
You will work collaboratively with primary care, community services, secondary care, social care and the voluntary sector (as appropriate and based on patient need). This will improve outcomes for patients and reduce healthcare costs.
The focus of the role is to identify and manage vulnerable patients (initially those with moderate and severe frailty and subsequently those living with long term conditions). This is fundamental to the delivery of the Integrated Care System (ICS) Frailty program. It is also fully aligned with the delivery of the ICS Integrated Care Strategy and NHS Joint Forward Plan addressing the specific needs of an ageing population and recognizing the economic and quality of life impacts of prioritizing frailty management.
Main duties of the job
Undertake daily identification of frailty and long-term condition workflows on E-Healthscope and decide the best course of action based on agreed Standard Operating Procedures (SOPs) and advice from clinicians/other key leads.
Proactively contact patients to complete the CFS and provide advice and refer to teams/services/local assets (where appropriate)
Undertake a holistic assessment/goal setting to ensure an advanced care plan is in place and agreed e.g. All About Me
Provide information to members of the PCN to aid communication
Complete relevant referral documentation and chase referrals as required and navigate and coordinate services to meet individuals needs across the PCN.
Access systems utilised across the ICS to support case analysis this includes but not limited to, Social Care, Mental Health and General Practice
Work closely with the integrated neighbourhood team for access to community-based activities
About us
We are aprovider of NHS Community Health Services, CityCare exists to support thehealth and wellbeing of all local people, working alongside other health andcare partners to achieve this. We are a value driven, people business with apassion for excellence. Our vision and social purpose is to make a differenceeveryday to the health & wellbeing of our communities and our values ofkindness, respect, trust and honesty lie at the heart of everything we do,guiding how we work together with partners and each other to consistentlydeliver high quality compassionate care. As a social enterprise we aim to addsocial value by investing in the future of our local communities and helping tomake a difference in peoples lives.
CityCare valuethe benefits of a diverse and inclusive workforce. We encourage applicationsfrom candidates who identify as disabled, LGBT+ or from a Black, Asian orMinority Ethnic (BAME) background, as they are currently under-representedwithin our organisation.
We are proud to be a forces-friendlyorganisation and are dedicated to supporting Veterans, Service Leavers, Reservists, andmilitary spouses/partners. We value the unique skills and contributions youbring.
CityCare is anequal opportunities employer. We are positive about employing people withdisabilities. If you require your application in a different format pleasecontact People Services on 0115 8839418. CityCare is committed to theprotection of vulnerable adults and children.
Job responsibilities
Job Purpose
To focus on the identification and management of vulnerable patients (initially those with moderate and severe frailty and subsequently those living with long term conditions). This refocus is fundamental to the delivery of the Integrated Care System (ICS) Frailty Programme.
To work in alignment with the delivery of the ICS Integrated Care Strategy and NHS Joint Forward Plan addressing the specific needs of an ageing population and recognizing the economic and quality of life impacts of prioritising frailty management
Dimensions
The post holder will work closely with Primary Networks (PCNs) acting as the named point of contact for information and a guide to processes for health and social care professionals within the PCN
The post holder will be accessible to patients members of the PCN via a dedicated telephone line between the hours of 8am and 6pm
Key Responsibilities
Undertake daily identification of frailty and long-term condition workflows on E-Healthscope and decide the best course of action based on agreed Standard Operating Procedures (SOPs) and advice from clinicians/other key leads.
Proactively contact patients to complete the CFS and provide advice and refer to teams/services/local assets (where appropriate)
Undertake a holistic assessment/goal setting to ensure an advanced care plan is in place and agreed e.g. All About Me
Provide information to members of the PCN to aid communication
Complete relevant referral documentation and chase referrals as required and navigate and coordinate services to meet individuals needs across the PCN.
Access systems utilised across the ICS to support case analysis this includes but not limited to, Social Care, Mental Health and General Practice
Work closely with the integrated neighbourhood team for access to community-based activities
Neighbourhood team MDT Meetings
Be responsible for facilitating regular (monthly as a minimum) multidisciplinary team meetings for each practice within the nominated PCN
Be responsible for arranging, attending and minuting the neighbourhood (MDT) meeting and compiling agendas and undertaking associated administrative work and initiating referrals within agreed format / process where appropriate following the discussions. All cases on the list will be reviewed and decisions logged on the risk of admissions register
Integrated Neighbourhood Team Meetings (INT)
Be responsible for co-ordinating INT meetings across the PCNs
Compile a list of patients to discussed in line with the standard operating procedure document, initiate any onward referrals
Data management
To contribute to the integration of health and social care by maintaining up to date recording systems for all agencies within the (MDT) team and providing information to any member of the neighbourhood team to ease processes and communication in agreement with data protection protocol
To be responsible for recording, reporting and producing evaluation reports which will include evaluation detailing effectiveness outcomes of new roles. To receive, breakdown and co-ordinate data and produce spread sheets for analysis (which shall include identification of referral trends and geographical spread of referrals and interventions to support the delivery of care within the PCN)
Support and undertake service monitoring, evaluation and documenting outcomes to ensure consistent delivery of high quality, effective and cost-effective services
Person Specification
Qualifications
* Excellent working knowledge of Microsoft Office software
* A-level / NVQ 3 or equivalent experience in admin / business / marketing / customer service environment
* Working knowledge of Excel and the management of data bases
Additional Criteria
* Ability to be flexible over hours worked within contracted hours to meet the needs of the service
* Ability to work out of hours
* Full driving licence and the ability to travel between locations.
* To participate in and fulfil the requirements of the Directors on-call arrangements.
Experience
* Experience of office procedures working at a high level as part of an administration team / within an administration role
* Experience of dealing with sensitive/confidential information
* Experience of working within Multidisciplinary teams
* Recruitment and selection skills
* Proven experience of supervising others, including carrying out appraisals and HR management procedures (including absence and performance)
Skills & Attributes
* Experience of working in Customer Care
* Assertiveness, ability to self-motivate and motivate others
* Understanding and able to deal with confidential and sensitive issues when liaising with team members / other professionals
* Ability to prioritise, organise and delegate workload to meet deadlines
* Excellent communication and listening skills
* Awareness of the barriers to effective communication
* Understanding of and commitment to equal opportunities and equity in service delivery
* Ability to work under pressure with constant interruptions requiring skills in multi-tasking, always maintaining accuracy
* Ability to problem solve and support others in resolving problems
* Ability to manage conflicting issues assertively and sensitively
* Remain calm under pressure
* Ability to plan and organise own and teams workload
* Be flexible in the management / involvement of development and change
* Knowledge and understanding of relevant health and social care legislation and initiatives
* Experience of supervising and training others on admin processes and procedures
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.
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