High Intensity User Lead

We are excited to recruit a full-time HIU Lead to support the launch of our new High Intensity Use (HIU) Service, a pioneering initiative within our Primary Care Network (PCN), made up of eight GP practices working in close partnership with neighbourhood teams.

The HIU Service supports individuals who frequently attend A&E or use emergency services more than expected. Many face complex challenges 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 to help people access the right care and improve their quality of life.

We welcome applications from individuals who are:

• Compassionate, curious, and committed to making a difference
• Skilled at building relationships and working across teams
• Tenacious, proactive, and able to work independently
• Passionate about helping people live healthier, more stable lives

This is a rewarding and varied role, offering the chance to be part of something new and meaningful. If you believe in better conversations, deeper understanding, and person-centred care we would love to hear from you.

Main duties of the job include:

• Work directly with individuals to explore what’s really going on in their lives
• Build trust and offer guidance tailored to each person's needs
• Connect people with appropriate services including health, housing, social care, and community support
• Take a collaborative, person-centred approach to reduce avoidable emergency service use

East Lindsey Primary Care Network is made up of general practices working together to deliver the best care possible to their patients. The practices are forward-thinking and supportive of all staff.

ELPCN offers a generous 5 weeks holiday and 8 bank holidays. Due to the geography, business travel to undertake the role will be paid.

The role will support the neighbourhood teams and practices in this new role to encompass the future of neighbourhood working.

The post holder will work as an employee of the East Lindsey Care Primary Care Network. It will be East Lindsey PCN's collective responsibility to lead to the transformation of culture, behaviours and attitudes of high intensity users of health care and changing the behaviour and wellbeing of the HIU client group.

The main focus includes unmet social needs that present as medical or mental health episodes to A&E. Other reasons why HIU individuals attend healthcare more than expected include homelessness, individuals who self-harm, and medical, social presentations. They may not be accessing scheduled services and therefore rely heavily on unscheduled services.

Our key expectations of the HIU lead role are:

• Positivity with a real sense of being able to strive for the impossible
• Generosity of spirit
• Ability to negotiate with stakeholders as well as the client themselves

A highly motivated, emotionally intelligent, and resilient person with leadership skills, whose drive is quality client care and who thrives off innovation. Lateral thinking, which is out of the box, is encouraged to support this vulnerable client group.

The Objectives of the Service are:

• Identify those at greatest risk of A&E attendance and non-elective admissions.
• Proactively work with a rolling cohort of HIU clients, really understanding what they need.
• 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 (possibly ambulance and police).
• Reducing A&E attendances and avoidable non-elective admissions.

More Difficult to Measure but Essential:

• 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 human outcomes observed.
• Act as a conduit to negotiate and de-escalate issues before a crisis occurs.
• Improving communication and partnership working between those involved in client care 24/7.
• Identify patterns and causal factors which trigger relapse behaviours in order to shape future commissioning of service and/or demand/capacity planning.
• Empower clients to self-manage to enable sustainable discharge.

The key outcomes that the proposed service will deliver are:

• Impact positively on reducing the high intensity use of healthcare.
• To support clients to flourish through sustaining job opportunities, reconnecting with families, improving well-being etc.
• A new culture of 1:1 coaching as a medium to deliver sustainable change.

The post holder is responsible for creating an innovative way of supporting the reduction in high intensity use of A&E. They will facilitate discussions and advise colleagues as to how best practice might be adopted for future development of the service and oversee their delivery.

Lead in removing potential barriers and stigma associated with HIU to promote equality, diversity and safeguarding service wide. The HIU Lead will act as an advocate for the client, guiding them through the complex journey and multi-faceted approach to encourage appropriate use of scheduled and unscheduled care services.

A further element of the role would be coordination, sharing and learning of the work with community-based staff to promote safe practice and sustainability. The post is responsible for providing professional expertise to the outcome of the business processes for the Lincolnshire Integrated Commissioning Board, including report writing and presenting evaluation reports.

Main Purpose of Job:

To provide holistic one to one person centred support for people aged 18 and over who have high dependency on emergency services and who are frequent visitors/callers of A&E, the Urgent Care Centre and East Midlands Ambulance Service.

To meet and collaborate with identified MDT partners to identify, discuss, and prioritise appropriate referrals from the patient cohort list. To work and collaborate with the voluntary and community sector, including Community Connector and wider Partnerships, to help identify appropriate referral destinations and to explore opportunities to meet gaps in services and activities.

To ensure effective record keeping and storage of patient data to demonstrate outputs and outcomes which is compliant with GDPR. To actively contribute as a member of a well-established social prescribing team and Neighbourhood network team who support the most vulnerable in society, contributing to the response to Population Health Management and Health Inequalities.

Key Tasks and Responsibilities:

1. To provide holistic one to one person centred support for people aged 18 and over who have high dependency on emergency services and who are frequent visitors/callers of A&E, the Urgent Care Centre and East Midlands Ambulance Service.
2. Carry out the role of a facilitator, broker, sign poster, community connector and navigator, acting as an enabler between the voluntary and community sector, patients, GPs and health clinicians, and social care.
3. Provide support to patients, generally in their own homes, up to 3-4 months to help direct and connect them to alternative sources of non-medical support services and activities.
4. Offer a personalised approach to sensitively uncover the real reasons for them calling 999 or presenting frequently at A&E/UCC.
5. During client visits undertake an assessment to gather baseline data and to identify the support needs and actions. Generating personalised care and support or wellbeing plans, which may include risk management.
6. Ensure support actions agreed with the patient are carried out by the service.
7. Support areas could include making referrals into a range of services provided by the voluntary, statutory or private sector, help with non-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 to peer led activities, initially taking patients to services if their confidence is low etc.
8. Once support has been provided carry out a final assessment.

To work and collaborate with the voluntary and community sector to help identify appropriate referral destinations and to explore opportunities to meet gaps in services and activities.

1. Keep abreast of a wide range of support services on offer in the voluntary and community sector through undertaking research, making connections with organisations and groups and by using a range of local online directories and Community Connectors.
2. Build and maintain positive relationships with a wide range of voluntary and community sector providers.
3. When gaps in services and activities are identified discuss and raise these with the team and if required liaise with voluntary organisations and Community Connector to help identify solutions.

To ensure effective record keeping and storage of patient data to demonstrate outputs and outcomes which is compliant with GDPR.

1. Ensure all patient records and actions are entered onto our record keeping systems.
2. Ensure GDPR requirements are adhered to in relation to data management.
3. When required, support in gathering any data required for working out cost savings to the wider health and social care sector as a result of the service interventions.

To actively contribute as a member of a well-established Neighbourhood team who support the most vulnerable in society.

1. Actively contribute to team meetings, away days, planning activities and reflective practice activities.
2. Share progress, learning and challenges within the existing Integrated Plus social prescribing team.
3. Share ideas about how the service could develop and evolve.
4. Adhere to all Lincolnshire CVS, Integrated Plus policies and procedures e.g. lone working, patient consent, information governance, and local governance policy and procedure etc.

Key Working Relationships:

• PCN EHCH Multi-Disciplinary Team
• Local Neighbourhood Team
• GP Practices within the PCN
• Practice Leaders (Partners and Practice Managers)
• Police
• PCN Clinical Director and PCN Project Manager
• Integrated Care Board (ICB) and NHSE
• Community Health Teams both physical and mental health
• Local Authority

Person Specification:

• Motivational interviewing.
• Coaching for Health and Wellbeing.
• Shared decision making or equivalent.
• Experience of supporting vulnerable adults in a person-centred way.
• Experience of working in the voluntary and community sector.
• 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.
• Ability 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.
• Passionate about making a difference to people's lives.
• 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.
• Ability to plan, prioritise and carry out your work in a flexible way.
• Accustomed to working on your own and in teams.
• Ability to use a range of software to produce written documents, spreadsheets, presentations.
• Effective management of communication by email, and comfortable using collaborative online tools.
• 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.
• 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.

Other employment requirements:

• Flexibility to work outside of core office hours.
• Access to own transport and ability to travel across the PCN locality on a regular basis.
• 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.