Health & Social Care Coordinator in London

The post-holder will be joining the Whole System Integrated Team (WSIC) at K&W Healthcare Ltd and will be providing case management and care planning to patients with long term conditions to improve their health outcomes and reduce the risk of hospital admissions and demand on secondary care. The Whole Systems Integrated Care (WSIC) service works with a wide range of partner organisations and stakeholders, including acute trusts, mental health trusts, local authorities, palliative care, community services and primary care, as well as voluntary sector organisations. Although open to all adult patients with long-term conditions, the major focus is on those aged 65+, helping patients to manage their conditions and remain healthy and active in the community. The Integrated Care Team works closely with the GP network in supporting patients and providing long term management through the Complex Patient Management Group (CPMG) and Multi-Disciplinary Groups (MDG). The post holder will ensure that our most vulnerable patients receive the co-ordinated care they depend on, care which is responsive to their needs and designed in cooperation with patients, carers and all supporting services.

Main duties of the job:

• Support the CPMG team and General Practices in the identification of appropriate patients for care planning and case management.
• Liaise with a range of health and social care providers including primary, community, social, third sector and secondary care to collate the necessary information about the patients for care planning and case management.
• Support patients and their nominated relatives through the care planning and case management process.
• Provide administrative, communication and performance management support at individual GP Practices as well as within the CPMG team.
• Be able to plan, organise and have good time management skills to prioritise their own workload.
• Work with a list of named patients with the aim of encouraging independence, alongside the GP and CPMG team, enabling people to remain at home.
• Reducing unnecessary admissions to hospital or attendance at A & E and supporting timely discharge from the Virtual ward.
• Provide feedback to the Practice and CPMG team, troubleshoot and escalate actions as necessary.
• Facilitate and ensure the effective delivery of patient-centred, personalised health and social care for patients, monitoring progress and reporting outcomes to the GP, Senior Nurse Case Manager and the CPMG team.
• Contribute to patient reviews and care planning within appropriate time frames.
• Liaise between services and service users, contacting services using the appropriate procedures.

About us:

K&W Healthcare's primary objective is to support GP Practices and services across the Brent localities of Kingsbury, Willesden and Wembley. Our aim is to develop quality primary care for patients within Brent and strive for continuous improvement in the delivery of primary healthcare services across our GP practices. K&W Healthcare is a GP-led organisation made up of 27 GP practices serving a registered population of over 220,000 patients. We are committed to improving the care provided to patients, reducing health inequalities and raising the quality and standards of GP practices.

Job responsibilities:

• Assemble and maintain statistics on the CPMG caseload and report weekly/monthly.
• Survey baseline data from Patients and staff within the CPMG.
• Input updates to personalised care plans and, under the direction of the GP, to patient records so they remain up to date and are evaluated and revised as necessary.
• Provide the patient/carer/service user with the most recent copy of their Care Plan where it has been updated.

The Post Holder will:

• Contribute to the development of this new service model by testing new ideas and suggesting changes where appropriate.
• Discuss improvement ideas with appropriate people and make suggestions to improve the service.
• Constructively identify and report where new ways of working/potential improvement to the service are required e.g. feedback from surveys.

Person Specification:

• Qualifications: Health & Social Care
• Experience in Primary Care
• 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.