Bank B7 Case Manager INW Central London Community Healthcare NHS Trust

The Case Manager will work within an integrated neighbourhood/care team (ICT/INT) to proactively undertake case finding, manage, co-ordinate and support patients with multiple complex long-term conditions using the whole systems integrated care (WSICS) dashboards. This role includes responsibility for ensuring all health and social care needs are met for risk stratification and managing frailty patient populations registered in the Primary Care Networks (PCNs) aligned to the ICT/INT.

The post holder will also support the health inequalities agenda through engagement of patients in the most deprived areas of the West London borough and work with key stakeholders on the wider determinants of health to improve outcomes, functional status and quality of life, ensuring integration of all elements of care, increase patient choice and prevent unnecessary admissions to hospital and reduce the stay of necessary hospital admissions.

The post holder will work as a minimum, 80% of their time in direct patient care. This will be spent supporting caseload allocation, providing practice development and education and competence support to the Case Managers and Health and Social Prescribing Coordinators. Work with the Primary Care Networks in the identification of those patients at high risk for acute hospital admission and ensure those identified are assessed and have care planned appropriately to reduce their risk of admission.

Empower patients and carers through appropriate support and education, ensuring care provided and service delivered are in line with National Service Framework, NICE Guidelines, Trust policies and procedures and the Clinical Governance Framework. Work with Community Practitioners on the promotion of patient self-management programmes within the local community.

Have clinical responsibility for practice caseloads including aspects of care delivery and co-ordination in line with service operating procedures. Support safer caseloads across the ICT/INT, minimizing service risk in relation to workflow and productivity, responding to referrals in a timely manner, acting swiftly to address waiting time portal breaches.

We provide community health services to more than two million people across eleven London boroughs and Hertfordshire. Every day, our professionals provide high-quality healthcare in people's homes and local clinics, helping them to: stay well, manage their own health with the right support, avoid unnecessary trips to, or long stays in, hospital.

We support our patients at every stage of their lives, providing health visiting for new-born babies through to community nursing, stroke rehabilitation and palliative care for people towards the end of their lives.

Our vision: deliver great care closer to home. Our mission: working together to give children a better start and adults greater independence.

Operational support and management for the Case Managers and Health and Social Prescribing Co-ordinators. Working with other Case Managers providing cover for GP practices during periods of absence and leave ensuring there is service cover and clear escalation processes for practice teams to contact. Leading and developing others through role modelling improved and evidence-based practice. Providing supportive and facilitative clinical leadership in ICT/INT forums.

Manage the day to day, ongoing delivery and development of the service that is responsive, high quality, value for money, and meets service specifications. Responsible for service delivery metrics, monitoring of performance activity reports i.e. referrals, hub/home visits, care plans, outcomes, and utilisation.