Are you looking for a new challenge? We are excited torecruit a full-time High Intensity User (HIU) Lead to support the launch of ournew High Intensity Use (HIU) Service, a pioneering initiative within our PrimaryCare Network (PCN), made up of four GP practices working in close partnershipwith neighbourhood teams.
The HIU Service supports individuals who frequently attendA&E or use emergency services more than expected. Many face complexchallenges including poor physical or mental health, housing instability,loneliness, or substance misuse. This service takes a person-centred approach,building trusted relationships and offering long-term, practical support tohelp people access the appropriate care and improve their quality of life. TheHIU Lead will work directly with the HIU client group, delivering a highly personalisedapproach that aims to improve wellbeing and health outcomes, whilst reducinginappropriate contacts with healthcare services, particularly unscheduled care.The HIU Lead will be dedicated to helping and supporting the HIU client groupto thrive, by fostering job opportunities, reconnecting with families,improving overall well-being.
The ideal candidate will be a highly motivated, emotionallyintelligent, compasstionate and resilient individual with strong leadershipskills. A commitment to high-quality client care and a passion for innovation.We encourage thinking "out of the box" to effectively support thisvulnerable group.
Main duties of the job
This is a non-clinical role focused on listening,understanding, and empowering.
Identify those at greatest risk of A&E attendance andnon-elective admissions.
Proactively work with a rolling cohort of HIU clients,really understanding what they need. Working with them in their homes or GP practice.
To coordinate wellbeing and connect with other services,enrolling them to help to get to the desired end.
Reducing 999 calls as a natural by-product (possiblyambulance and police).
Reducing A&E attendances and avoidable non-electiveadmissions.
Drive equality and client voice.
Forming robust network of community health, social care,mental health and police to manage clients, creating true integrated working.
Providing a service driven by quality with positive humanoutcomes observed.
Act as a conduit to negotiate and de-escalate issues beforea crisis occurs; a situation which has historically led to a destabilisation oftheir condition and resulting in a A&E attendance / 999 calls.
Improving communication and partnership working betweenthose involved in client care 24/7.
Identify patterns and causal factors which trigger relapsebehaviours in order to shape future commissioning of service and/ordemand/capacity planning.
Empower clients to self-manage to enable sustainabledischarge.
About us
Meridian Medical Primary Care Network is agroup of GP Practices coming together to share their experience, workforce andservices, with the aim of improving access and meeting the needs of localpatients and communities. In doing this, we can provide better quality services,closer to where patients live and are varied to meet their needs.
The four GP Practices are: East Lindsey Medical Group in Louth &Tetford, James Street Family Practice in Louth, Marsh Medical Practice in NorthSomercotes and Manby and Tasburgh Lodge in Woodhall Spa, who all work together to deliver the best possible care for our patients, along with health and care partners, LCHS, patient organisations and the voluntary sector across Lincolnshire, as well as working across borders. The PCN serves a population of approximately39,000 patients.
You will be employed by East Lindsey Medical Group and dueto the geography of the PCN, business travel to undertake the role will bepaid.
The role will support Meridian Medical PCN and its GPpractices and neighbourhood teams and truly encompass the future ofneighbourhood working.
Our Vision: Our vision is a community whereeveryone feels valued, has a sense of belonging and can achieve what isimportant to them.
Our Mission: Our mission is to join up our practiceswith other health and care providers, charities and community groups, so thateveryone in our community receives the level of support they need, when theyneed it, close to their home.
Job responsibilities
Key Tasks and Responsibilities
1. To provide holistic one-to-one-person centred supportfor people aged 18 and over who have high dependency on emergency services andwho are frequent visitors/ callers of A&E, the Urgent Care Centre, and EastMidlands Ambulance Service.
Carry out the role of a facilitator, broker, sign poster,community connector, and navigator, acting as an enabler between the voluntaryand community sector, patients, GPs ,health clinicians, and social care.
Provide support to patients, generally in their own homes,up to 3-4 months to help direct and connect them to alternative sources ofnon-medical support services and activities.
Offer a personalised approach to sensitively uncover thereal reasons for them calling 999 or presenting frequently at A&E/UCC.
During client visits undertake an assessment to gatherbaseline data and to identify the support needs and actions. Generatingpersonalised care and support or wellbeing plans, which may include riskmanagement.
Ensure support actions agreed with the patient are carriedout by the service. Support areas could include making referrals into a rangeof services provided by the voluntary, statutory or private sector, help withnon-means tested benefit form filling e.g. Personal Independent Payments,Attendance Allowance, housing forms etc, distributing food bank vouchers,identifying suitable volunteering opportunities, connecting people into peer topeer led activities, initially taking patients to services if their confidenceis low etc.
Once support has been provided carry out a final assessment
2. To meet and collaborate with A&E clinical staffregularly, to discuss, identify and agree appropriate referrals from thepatient cohort list (patients presenting more than 12 times per year) and otherpatients presenting less than 12 times per year at A&E.
Meet with a range of health clinicians to discuss and agreeappropriate referrals from the patient cohort list.
Build and maintain positive relationships with a range ofhealth professionals.
Work closely with health clinicians to facilitate optimaljoint working on safe and effective care for patients with complex needs.
Raise awareness of voluntary and community sector activitiesand services on offer to showcase the diverse range of services available tohealth and social care practitioners.
Raise awareness of the social prescribing service withhealth practitioners.
With health professionals and a range of providers identifyservice needs, broker solutions and when required enable individuals to besupported to kick start/lead on new activities through Lincolnshire CVS.
3. To work and collaborate with the voluntary andcommunity sector to help identify appropriate referral destinations and toexplore opportunities to meet gaps in services and activities.
Keep abreast of a wide range of support services on offer inthe voluntary and community sector through undertaking research, makingconnections with organisations and groups and by using a range of local onlinedirectories and Community Connectors.
Build and maintain positive relationships with a wide rangeof voluntary and community sector providers.
When gaps in services and activities are identified discussand raise these with the team and if required, liaise with voluntaryorganisations and Community Connector to help identify solutions.
4. To ensure effective record keeping and storage ofpatient data to demonstrate outputs and outcomes which is compliant with GDPR.
Ensure all patient records and actions are entered onto ourrecord keeping systems.
Ensure GDPR requirements are adhered to in relation to datamanagement.
When required, support in gathering any data required forworking out cost savings to the wider health and social care sector as a resultof the service interventions.
5. To actively contribute as a member of awell-established social prescribing and Neighbourhood team who support the mostvulnerable in society.
Actively contribute to team meetings, away days, planningactivities and reflective practice activities.
Share progress, learning and challenges within the existingIntegrated Plus social prescribing team.
Share ideas about how the service could develop and evolve.
Adhere to all Meridian Medical PCN policies and procedurese.g. lone working, patient consent, information governance, and localgovernance policy and procedure etc.
Person Specification
Qualifications
* Essential Qualifications
* -No formal qualifications are required but you must have high emotional intelligence and resilience, be a win-win negotiator, and be brave enough to change the culture around high-intensity use of services.
* -The candidate needs to shine and connect well in interviews to demonstrate these skills.
* -Motivational interviewing
* -Coaching for Health and Wellbeing
* -Personalised Care Institute e-learning modules, PCSP, shared decision making or equivalent.
Experience
* -Experience of supporting vulnerable adults in a person-centred way.
* -Experience of working in the voluntary and community sector.
* -You have the ability to work sensitively in difficult emotional circumstances with empathy, compassion, respect and understanding.
* -Knowledge of asset/strength-based recovery models and approaches
* -Experience of case load management.
* -You will be able to cooperate with a range of health professionals, voluntary sector providers and people around the range of possibilities that might be available in enabling service provision to be more holistic to improve mental health and wellbeing of vulnerable people.
* -You are a person who is willing to go the extra mile for a person to ensure they get the right care and support. You are passionate about making a difference to peoples lives
* -You possess a strong and practical understanding of safeguarding policy and practice and are up to date with current legislation.
* -Excellent communication and interpersonal skills.
* -Experience of working in teams.
* -Experience of collaborative working.
* -Knowledge and understanding of equality and diversity.
* -Knowledge and understanding of GDPR.
* -You can plan, prioritise and carry out your work in a flexible way. You are accustomed to working on your own and in teams.
* -Adaptability, flexibility and ability to cope with uncertainty and change.
* -Demonstrate ability to work in a busy environment; ability to deal with both urgent and important tasks and to prioritise effectively whilst also supporting others.
* -Excellent time keeping and prioritisation skills.
* -You know how to use a range of software to produce written documents, spreadsheets, presentations. You can effectively manage communication by email, and you are comfortable using collaborative online tools (for example WhatsApp, Twitter, Facebook, using text editors such as Word/Pages and other message apps.
* -Access to own transport and ability to travel across the PCN locality on a regular basis
* -Experience of working within the community, voluntary and/or primary care.
* -Flexibility to work outside of core office hours
* -Experience of providing social prescribing interventions
* -Knowledge of health and social care
* -Local knowledge of the voluntary and community sector
* -Ability to use Microsoft 365
* -Specific Aptitudes Awareness of equality and valuing diversity principles Understanding of Confidentiality and Data Protection Act
* -Self-motivated and proactive
* -Continued commitment to improve skills and ability in new areas of work
* -Able to undertake the demands of the post with reasonable adjustments if required
* -Ability to work from home on some occasions where tasks allow
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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