Reports to: Project Manager
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.
Job Summary:
The Post Holder will:
- 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.
- Facilitate effective delivery of patient-centred, personalised health and social care for
patients, by monitoring progress and reporting outcomes.
- Ensure personalised care plans remain up to date and that they are evaluated and revised as
necessary.
- Ensure contact is made with each person 'accepted' onto the CPMG and the proposed plan of care is communicated following liaison with the Senior Nurse Case Manager.
Main Duties and Responsibilities: Supporting the Delivery of Care
The Post Holder will:
- Set up and service the weekly CPMG meetings.
- Document referrals, assemble any relevant paperwork and draw up a list of patients prior to
the CPMG meeting.
- Ensure that the actions set out following CPMG meetings are followed up and that actions
from different professionals are co-ordinated around individual personal needs.
- Be a direct point of contact to the patient, carer or service user and the CPMG team.
- Following the discharge of persons from the CPMG, carry out further actions to monitor their
progress, as directed by the CPMG team.
Data Monitoring, Input and Sharing
The Post Holder will:- Assemble and maintain statistics on the CPMG caseload and report weekly/monthly.
- Collect (via surveys) 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).
Other Responsibilities In addition the Post Holder will be required to:
- Provide cover for other HCA/HSCCs as needed to cover leave, sickness absence and training.
- Identify, and report any issues of concern relating to safeguarding and quality of care.
- Participate in the induction and training of new members of staff.
Place of Work
This Post will be based at Willesden Medical Centre with a requirement to visit patients both in
their homes and at their GP Practices across Kingsbury and Willesden.
In addition there may be a requirement to attend any of K&W Healthcare’s member practices to discuss the needs of patients with their registered GP.
Communication The Post Holder will recognise the importance of good communication and will strive to:
- Communicate effectively with colleagues.
- Be polite and courteous at all times and communicate relevant information where
appropriate.
- Communicate with a range of different stakeholders including Healthcare providers, Social
Care providers, Voluntary Sector providers, and patients with complex physical and mental
health needs;
- Modify communication style and medium as appropriate to the needs of the stakeholder.
- Maintain the highest standards of integrity when communicating with patients and the wider
public, taking account of others culture, language, background and preferred way of
communication, respecting patient confidentiality.
- Be a contact point and establish systems and processes which will ensure timely and
appropriate responses to queries from clinicians, patients and others, along with the Case
Manager.
- Demonstrate an ability to convey complex information, both verbal and written, providing
reports as required.
Confidentiality
In the course of seeking treatment, patients entrust providers with, or allow the providers to gather, sensitive information in relation to their health and other matters. They do so in confidence and
have the right to expect that staff will respect their privacy and act appropriately. Under the Data Protection Act 1998, the Post Holder must maintain the confidentiality of information about patients and ensure confidential information is handled and kept safe and secure, following all information governance rules and regulations.
This work is of a confidential nature and information gained must not be communicated to other persons except in the recognised course of duty. Unauthorised disclosure of confidential
information will result in disciplinary action and may lead to the Post Holder’s dismissal.
Equal Opportunities It is the aim of K&W Healthcare Limited to ensure that no job applicant or employee receives less than favourable treatment on the grounds of their sex, marital status, race, colour, creed, religion, physical disability, mental health, learning difficulty, age or sexual orientation and is not placed at a disadvantage by conditions or requirements that cannot be shown to be justifiable. To this end
Equality and Diversity The Post Holder will support the equality, diversity and rights of patients and colleagues, which will include:
- Acting in a way that recognises the importance of people’s rights and interpreting them in a
way that is consistent with the company’s procedures and policies and current legislation.
- Respecting the privacy, dignity, needs and beliefs of patients and colleagues.
- Behaving in a manner which is welcoming to the individual, is non-judgmental and respects
their circumstances, feelings, priorities and rights.
Health and Safety Employees must be aware of the responsibilities placed on them under the Health and Safety at Work Act (1974) to ensure that the agreed procedures are carried out to maintain a safe
environment for patients, visitors and staff. The Post Holder will assist in the promotion and
maintenance of their own and others’ health, safety and security as defined in the company’s
Health and Safety Policy, which will include:
- Promote the health safety and security of yourself and others you work with, including
patients and their carers.
- Using personal security systems within the workplace according to company’s guidelines.
- Identifying the risks involved in work activities and undertaking such activities in a way that
manages these risks.
- Making effective use of training to update skills and knowledge.
- Using appropriate infection-control procedures and maintaining work areas in a tidy and safe
way ensuring that they are free from hazards.
- Ensure compliance with legislation, policies and procedures both in the workplace and on
home visits.
- Reporting any potential risks as they are identified.
No Smoking Policy
The company has a strict No Smoking Policy as part of its responsibility for the provision of health.
The Post Holder will be required to work within the framework of this policy. Smoking is not
permitted anywhere within the company buildings or at any locations where services are provided.
Personal and Professional Development The Post Holder will participate in any training programme implemented by the company, and will:
- Identify and take responsibility for own development needs and accept feedback positively.
- Produce and keep a Personal Development Plan.
- Contribute to the development and enhancement of other professionals in the GP practices.
- Share 'best practice' where applicable.
- Participate in regular/annual Appraisal.
- Comply with mandatory training programmes.
- Actively contribute to the leaning needs of other Health and Social Care Coordinators.
- Display a detailed knowledge of local support services that could be deployed to assist
individuals to achieve optimum health and social care.
- Establish excellent networking skills to co-ordinate effective, positive and responsive packages of care for service users.
- Demonstrate a commitment to personalisation and support patients/carers/service users to
procure relevant and effective services.
Quality The Post Holder will strive to maintain quality within the company, and will:
- Work within the limits of their own competence and areas of accountability.
- Seek help and advice where needed.
- Alert other team members to issues of quality and risk.
- Assess own performance and take accountability for own actions, either directly or under
supervision.
- Contribute to the effectiveness of the team by reflecting on own and team activities and
making suggestions on ways to improve and enhance the team’s performance.
- Work effectively with individuals in other provider organisations to meet patients’ needs.
- Prioritise own workload and manage own time to ensure priorities are met and quality is not
compromised.
Flexibility
The company is currently working in a climate of great change within the NHS. It is, therefore,
expected that all staff will develop flexible working practices to be able to meet the challenges and opportunities of working within the evolving NHS.
Note: This job description is a reflection of the current position and the Post Holder is expected to view it as a guide rather than an exact description of all duties and responsibilities. It may
be varied from time to time in consultation with the post holder. The Post Holder will need to
be flexible in developing the role further and in participating in initial and ongoing discussions
with the designated manager.
