Network Care Coordinator - Frailty Care Coordination MDT Pilot

The role will directly support the delivery of proactive care in the South-EastNeighbourhood of Tower Hamlets supporting people with frailty needs who would benefit from coordinatedcare. Thiswill be achieved by bringing together all the information about a person'sidentified care and support needs and exploring options to meet these within asingle personalised care and support plan, based on what matters to the person.

The job holder will organise and lead on monthly multi-disciplinaryteam meetings and have the opportunity to improve leadership skills,championing the proactive care model in the Neighbourhood and working with leadclinicians and professionals in the local authority and voluntary sectors.

The successful candidatewill be based in either of the two Primary Care Networks in the South-East Neighbourhood.They will be caring, dedicated, reliable, person-focused and enjoy working witha wide range of people. They will have good written and verbal communicationskills and strong organisational and time management skills. They will behighly motivated and proactive with a flexible attitude, keen to work and learnas part of a team and committed to providing people, their families and carerswith high quality support.

Main duties of the job

To work with our Network of practices to provide a central coordination role in patient care planning and delivery, putting in place a Personalised Care Support Plan, referring to health and social professionals as needed and to administer and lead monthly Multi- Disciplinary Team Meetings.

About us

The Tower Hamlets South-East Neighbourhood is a partnership of 8 local general practices, community care teams, and local third-sector providers. It strives to deliver the best outcomes for its patients through a joined-up approach, quality access and equality of GP services. The successful candidates (x 2) will be joining a team of health professionals dedicated to provide integrated and patient-centred care, working on this 12 month Frailty Care Coordination MDT Pilot. If you are qualified, experienced and ready for a new challenge, why not join us!

Job responsibilities

Key responsibilities of the post

a) Identify residents who would benefit from a Proactive Care approach

Coordinate the list of residents who fit the criteria of 65+, moderately frail, with COPD/CVD and are frequent hospital attendees and who could be supported by a Multidisciplinary Team (MDT) approach

Put in place for each resident who fits the criteria a Personalised Care and Support Plan, using EMIS

Cross-reference lists with relevant patient records (and other systems as appropriate) togain an understanding of the different professionalsinvolved in the care of the resident

Work with the relevant practitioners to prioritise the cohort list

Work closely withpractitioners to develop an increased awareness of households and patientswho may be vulnerable and in need of support

b) Have discussions with residents focusingon what matters to them

Contact the resident to explain the proactive care offerand invite involvement

Carry out a holistic strengths-based assessment of need, and buildtrust

Communicate with the frailty and long-term conditions team withregards to health outcomes or any further assessment required

c.Be a core part of Network Team MDTs

To act as a key member of the network MDT leading and supportingthe development of effectivemeetings

Organise and lead monthly locality frailty care coordination MDTmeetings

Attend Neighbourhood meetingas part of MDT i.e. frailty, COPD, CVD meetings

Bring for discussion patients identified for the proactive carepathway to the MDT

Work with practitioners to ensure that relevant professionalsinvolved in the care and support ofthe individual are involved in MDT discussions where appropriate

d.Coordinate support for the resident

Support people in managing their needs

Support people to take up training and employment, and to access appropriate benefitswhere eligible

Assist people in accessing self-management education courses, or interventions that enable them to supporttheir health and wellbeing

Provide coordination and navigation for people and their carersacross health and care services

Signpost residents to frailty, COPD and CVD and other relevanthealth services

Signpost and work with local authority team to support residentscare needs and wider determinants of health (housing, blue badge, employmentetc.)

Maintain accurate, confidential and up-to-date documentation on residents, includingpatients EMIS records

Keep MDT related information up to date (agenda, minutes,follow-up actions)

Ensure safeguarding arrangementsare in place to supportthose residents identified for support

Maintain monitoring and reporting templates up to date

f.Evaluate outcomes for individual residents

Support people to understand their level of knowledge, skills andconfidence when engagingwith their health and wellbeingusing relevant goals-based measures

With the wider Neighbourhood,gather and collate information, evidence and anonymised stories, reporting on outcomes and activity. Ensure effectivequalitative and quantitative monitoring and evaluation

g.Leadership

Opportunity to champion the deliveryof proactive care within the Neighbourhood, through a successful programmeimplementation

Opportunity to work closely with practices in coordinatingresidents if needed

Attend management meetings to update progress and concernsrelating to the proactive care programme when required

h.Working with others

Be an active member of the Neighbourhoodteam tobuild relationships with General Practice,adult community nursing,adult community therapies,mental health, adult social care and voluntary sector staff. Attend relevant servicemeetings, forums and contribute to continuous improvement of the Neighbourhood team

i. Supervision and training

Proactively engage in training and support made available and undertake appropriate training with the Personalised Care Institute

Person Specification

Knowledge

• Understand the opportunities and challenges of working in a diverse, inner city area
• Commitment to reducing health inequalities and proactively working to reach people from all communities
• Understanding how integrated working supports residents in a holistic way
• Awareness of frailty, long-term conditions, poor health and the complexities involved physical, emotional and social
• Knowledge of how health and social care works including primary care
• Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety
• Knowledge of PCNs, Neighbourhood, locality and the borough of Tower Hamlets

Qualifications

• Educated to GCSE level (or equivalent by experience).
• NVQ Level 4/5 or equivalent.
• Demonstrable commitment to professional and personal development

Experience

• Worked in statutory or voluntary sector services
• Worked in supportive roles that involved direct contact with the public, their families or carers (in a paid or voluntary capacity)
• Worked in multi team environments
• Been involved in or provided coordination support for MDTs
• Worked in a Care Coordinator role or across adult health and social care or Public health improvement

Skills

• Able to communicate effectively, both verbally and in writing, with residents, their families, carers, community groups, partner agencies and stakeholders
• Ability to use EMIS, Microsoft Office applications Word, Excel, PowerPoint, Outlook
• Ability to collate and analyse data and use tools to measure impact
• An understanding of the importance of accurate and timely documentation, confidentiality, and safe information sharing
• Ability to listen, empathise with people and provide person- centred support in a non-judgmental way
• Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity
• Able to support people in a way that inspires trust, motivating others to reach their potential
• Commitment to collaborative working and the ability to maintain effective working relationships
• Personal accountability, emotional resilience and works well under pressure
• Ability to identify risk and assess/manage risk when working with individuals
• Ability to work flexibly and enthusiastically within a team or on own initiative
• Proficient speaker of another language to aid communication with people in the community for whom English is a second language
• A strong awareness and understanding of when it is
• appropriate or necessary to refer people back to other health professionals/ agencies

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 name

£28,000 to £34,000 a yearincludes high cost area supplements (HCAS)