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Neighbourhood Working describes an integrated approach to managing patients, through a blended workforce that encompasses both health and social care; to include acute, voluntary and community sectors where barriers to working are negated, the health and wellbeing needs of the individual are at the centre of decision-making, care is proactive and not reactive, and services are provided in a timely manner.
Key outcomes of neighbourhood working have been identified as:
- Enabling people to remain in, or close to, their own home, whenever possible.
- Proactive care provision
- Improving pathways between services, reducing inefficiencies, fragmentation, and duplication of care
- Improved communication and working relationships between individuals and providers
- Improving access to, and information about services
- Continuity of care
- Increasing out of hospital care provision
The Neighbourhood Care Coordinator will provide a crucial interface between all staff groups that contribute to Neighbourhood Working. The Neighbourhood Care Coordinator will have overall responsibility for the co-ordination of the regular Multi-Disciplinary meetings and be responsible for personalised care planning and tracking patient caseloads. They will support a system approach, providing a responsive element to the front door of all South West Neighbourhoods.
- Provide direct support to patients and their carers to identify needs, working with PCN colleagues to deliver good quality individualised care and support.
- Coordinate and manage administrative functions which will include ensuring that meetings are organised and recorded appropriately.
- Work closely, and communicate effectively with, the local Primary Care network colleagues including the Neighbourhood Team Lead Support peoples needs using population health management techniques and stratification to support proactive approaches in the community and on discharge from hospital.
- Support operational delivery of South West Lincolnshire Care Coordination model.
- Support a range of projects within scope of the Neighbourhood, aligned to Neighbourhood Team workstreams.
- Manage nominations for Neighbourhood MDT review from all health, social and voluntary care organisations and ensure all associated documentation pre and post review is completed.
- Support the Head of Integrated Neighbourhood Working to seek alternative provision or escalation, where the MDT/Virtual MDT have not achieved anticipated outcomes for individuals.
- Liaise with all professionals involved in the persons care including primary, secondary/emergency and community care services including mental health provision, carers, third sector organisations and other relevant groups.
- Identify opportunities to develop the neighbourhood, as well as blockers and inefficiencies in the system. Feedback to the Head of Integrated Neighbourhood Working and participate in and support initiatives for development.
- Facilitate and organise training events and networking engagement events.
- Support local initiatives with partner organisations to widen the influence of the neighbourhood teams and to ensure local projects are co-ordinated across the area.
- To undertake visits to promote and advertise the work of the neighbourhood e.g. attend and present to organisations team meetings. Be responsible for feeding back actions undertaken.
- To deal in a professional, helpful and effective manner with members of the neighbourhood, and outside agencies, about neighbourhood business, referring queries on as appropriate.
- To take basic patient observations and inform clinical team when observations fall outside of normal parameters.
- To input data onto the patient information management system (S1) to update patient records, including outcomes of reviews, planned interventions/assessments, patient details, and periodically use reports to ensure service user details are correct.
- Develop knowledge of local services and to understand how services are accessed, ensuring information is accessible to all.
- Communicate with other members of the Neighbourhood as people need further intervention to prevent unplanned hospital admission or to facilitate discharge, as appropriate.
- Maintain a network of contacts with other Lincolnshire Neighbourhoods in order to share good practice and new ideas.
- To prepare communications to the neighbourhood to include service updates, service changes and any other relevant information.
- Any other duties as deemed appropriate by the Head of Integrated Neighbourhood Working.
- Be willing to work flexibly and travel across the county. You will be required to provide some cover for colleagues in their absence.
SKILLS REQUIRED FOR THE POST
Communication and relationship skills:
- Acts in a dignified and responsible manner with patients, carers and colleagues, using appropriate language and communication skills, which acknowledge barriers to understanding, cultural differences and diversity.
- To provide supportive and sensitive communication, written and verbal advice to patients, carers and staff, whilst demonstrating an understanding of the nature and effects of some information and of barriers to effective communication e.g. sensory or cognitive impairment and patient expectations whilst being considerate of patient confidentiality.
- Develop and maintain communication (sensitive, complex and contentious) with teams, organisations and agencies, to promote good patient care.
- To confidently convey written and verbal information on both clinical and non-clinical issues and to colleagues within the network.
- Act as an advocate to support patients both physically and psychologically to achieve expected outcomes, explaining care, treatment and associated risks.
- Provide and receive information where persuasive, motivational, negotiating, empathic and re-assurance skills are required to support patients.
- Maintain strict confidentiality sensitive patient information at all times.
- To use verbal and non-verbal skills to educate patients and carers empowering patients and carers to be active in the planning process.
Analytical and judgment skills:
- To support patients to engage in care plans as directed by Clinical colleagues.
- Extract caseload information and undertake analysis including running reports and converting data into charts and tables for sharing with the team.
- A good standard of Information Technology skills.
- Good report writing skills
Planning and organisational skills:
- Organise and plan activities with patients, both individually and where need arises through facilitating group sessions.
- Ability to manage and prioritise own workload and time and be flexible in response.
- To be proactive and creative in supporting patient care.
- To ensure relevant administration, personnel and safety polices are adhered to.
- Plan and organise activities including organising meetings on behalf of a number of stakeholders.
- To manage and prioritise workload on a daily basis and deal with competing demands of the Neighbourhood.
Physical Skills:
- Requirement to adhere to individual risk assessments.
- To have the ability to drive for a moderate percentage of the working day to carry out community visits.
- To be able to physically support patients including being able to facilitate standing, walking and sitting during treatment sessions in accordance with safe nationally agreed
Moving and Handling Guidelines:
- To manoeuvre, set up and adjust items of equipment. IT skills and keyboard competency using Microsoft Windows and local operating systems.
RESPONSIBILITIES OF THE POST HOLDER
Responsibilities for direct/indirect patient care:
- Assist patients, carers and families during incidental contact e.g. signposting and answering routine enquires.
- Assist patients carers and families through completion of Personalised Care and Support Plans Regular contact with service users, carers and the public.
Responsibilities for policy and service development implementation:
- Follow policies/implement policies and propose changes in working practices or procedures for own area.
Responsibilities for financial and physical resources:
- Personal duty of care in relation to equipment / safe use of equipment.
- Costing events and activities and liaising with the budget holders
Responsibilities for human resources:
- Demonstrate own activities to new or less experienced employees.
- Regular requirement to develop or create reports or documents.
- Responsible for maintaining one or more information system, which is a significant job responsibility e.g., inputting into systems and databases to collect and monitor information, maintains and updates to ensure patient details are correct and track patient care management.
Responsibilities for information resources (including systems access):
- The postholder will use the systems as outlined below and record personally generated information:
Systems Required to Access:
- Patient Flow Software
- Microsoft Word, Powerpoint, Excel
- ESR
- SystmOne
- NHS net email
- Care Portal
- Level of Responsibility
Responsibilities for research and development:
- Core User / Reviewer
- Own data
- Own data entry dependent on employer
- Core user
- Personal use Core User / Reviewer when operational
- Undertakes surveys or audits, as necessary to own work e.g. requirement to undertake surveys appropriate to own work or carries out research as required.
- Identify opportunities to develop the Neighbourhood Coordination Model, as well as blocks and inefficiencies in the system, and feed back to the Head of Integrated Neighbourhood Working. Participate in, and support, initiatives for development.
FREEDOM TO ACT
Defined occupational policies and works within organisational policies and procedures.
EFFORT & ENVIRONMENT
Physical effort
- The role is community and office based and will require the post holder to frequently sit and stand with a requirement for sitting in a restricted position when attending meetings which will be a regular part of the role as well as travelling to and from work bases and clinical visits.
Mental effort
- Frequent concentration, work pattern unpredictable. Concentration required for data analysis, tracking service users and meetings, frequent interruptions requiring urgent attention and re- prioritisation of work.
Emotional effort
- Frequent indirect distressing or emotional situations, e.g. exposure to details of patients needs.
Working conditions
- The post is office based, and there is a frequent requirement to travel within the locality. Use of VDU equipment.
K2 Healthcare Ltd is a GP federation constituted of 16 member GP Practices in South West Lincolnshire with two Primary Care Networks and supporting a population of 133,000 people.
K2 works together to share resources and expertise that enable practices to provide shared services and business systems to provide the best possible care for our population, ensure sustainability, growth and value for GP practices and system partners within available resources.
The Lincolnshire Integrated Care System sees us working in a provider collaborative with the Primary Care Network Alliance, Secondary Care, Community Health, Mental Health, Social Care as well as Local Authorities, and the Community and Voluntary Sector. How we do it is as important as what we do and relationships with our partners is at the core of everything we do.