Care Co-ordinatorinWokinginWokingPUBLISHED WED 23 OCT 2024

CSH Surrey and North West Surrey stakeholders have developed an integrated neighbourhood model of care supporting adult patients with one or more long term condition(s) to actively promote wellbeing and independence, with a view to improving health and social care outcomes and patient experience of health and social care services.

You will be working closely with Health and Social care Teams, GPs, acute Trusts, District & Boroughs and key Partners, including the Voluntary Sector to achieve this. This role has been developed to provide a practical front-line support service, using assessments to identify and develop care and support plan(s) to meet the assessed needs of people accessing the Integrated Neighbourhood team, in partnership with professional staff in other agencies and service providers. They will help people with information, advice and guidance; and work as part of the multi-disciplinary team and community to ensure provision of support for people accessing health and Care services. Care Coordinators will also be expected to support with the Virtual Wards within the Neighbourhood Business Unit. This vacancy will be in the Woking locality.

UK Visa and Immigration Sponsorship: Please note that we do not offer UKVI sponsorship for these posts, and so all applicants require a current right to work in the UK.

The role holder will provide a practical front-line support service, using assessments to identify and develop care and support plan(s) to meet the assessed needs of people accessing the Integrated Neighbourhood Services, in partnership with professional staff in other agencies and service providers. They will help people with information, advice and guidance;

This may include working with people with a frailty; people with physical impairments; people with mental, sensory, cognitive impairments; people with a learning disability; and supporting End of Life care. They will work within the multi-disciplinary team under the supervision and guidance of the Clinical Leads and Community Well-being manager.

The post holder will be responsible for the coordination of care and support to patients supporting them from the point of referral. The Care Coordinator ensures that patients who are supported at neighbourhood level, are supported in the right place, by the right person, at the right time.

The post holder will facilitate the delivery of high levels of patient care and will ensure that patients and clinicians have a good experience by being an accessible, customer focused and knowledgeable point of contact.

About us

To work as part of the Integrated Neighbourhood Team, (INT) ensuring that people who are supported through the INTs are guided through their required pathway efficiently. Referrals could include making arrangements for home visits, assessments, referral for diagnostic procedures or admission for a limited time to the Virtual Ward, or referral onto other disciplines such as health or social care or voluntary services.

Following initial triage, the role holder will be the point of contact with the service, gathering initial information, providing guidance, initiating and carrying out assessments, as well as signposting them to other services. This range of providers will include District and Borough Councils, Family, Friends and Community Support, and other agencies including but not limited to NHS Continuing Healthcare, Carers support groups, and Charities.

Create, monitor, manage and coordinate multi-disciplinary care, support plans for people which are Care Act compliant and meet their needs in line with partner organisations.

Engage effectively with people and their families to facilitate contingency planning to anticipate complexity and changing circumstances. Ensure proportionate reviews are completed so that people have the opportunity to reflect on what is working, and what needs to be changed, and can do so in a person-centred, outcome-focused way.

Ensure that independent advocacy services are utilised when required to enable engagement in the assessment process.

Attend meetings as part of the INTs across North West Surrey as required.

To coordinate and book appointments, including transport, as required.

To attend multi-disciplinary team meetings as part of the INT, including GP practices and other organisations where appropriate.

To ensure that the information on the individuals records is recorded accurately and comprehensively on the patient information systems (RIO, EMIS or other).

Check patient identity details including all demographic information during patient encounters.

Ensure that information distributed to people to be supported by the team is accurate and current.

Be pro-active, establish and maintain regular contact with people identified as at risk of admission to hospital to facilitate such people to remain at home. If they experience deterioration in their condition such people will be escalated to the relevant health or social care colleagues, dependent on their care plan.

To act as a key point of contact and provide a central point of contact for people to be supported by the service and the range of professionals involved in their care.

Assist in development and project work, and work with other staff to provide information and feedback. For example, Virtual Wards, or information sharing events.

As the first point of contact liaise with partner organisations to assist in the assessment and provision of care of people to be supported through the service.

This includes liaison with primary, secondary, social and tertiary care providers ensuring that information is recorded and/or provided at the point of receipt of referral.

Assist the wider community INT in sourcing and delivering care and support i.e. home based care, Community Hospitals, residential and nursing care, respite care, support through voluntary organisations and support for carers to be able to offer local knowledge of the range of health and social care services available for people to be supported by the service.

Be aware of the needs and concerns of people who can be supported through this service and provide a friendly, efficient and courteous service to patients, relatives and visitors, providing them with advice and information as appropriate. Use empathetic approach to patients and/or relatives seeking assistance from clinical staff/senior managers as appropriate.

Identify and manage risk associated with open cases to ensure safeguarding of people on the caseload. Make use of line manager/supervisor to escalate risks when necessary.

Conduct standard assessments of service users circumstances and issues, recommending onward referrals, to ensure protection of vulnerable individuals.

Provide caseload management as allocated by senior colleagues, working within guidelines and

procedures, and record the individuals progress.

Support people to access community opportunities and work directly with users, providing advice and support to facilitate independence.

Plan, organise and supervise allocated activities within procedural and regulatory framework. Typically deal with multiple cases and/or groups at one time.

Assist in the induction of new colleagues by sharing expertise and knowledge within the team.

Duties for all values: To uphold the values and behaviours of the organisation.

They will develop and maintain an understanding of the work being done at place, (including voluntary organisations and community resources), to have a good working knowledge and relationship with those services. These interrelationships are crucial to the success of finding creative solutions and services, to ensure independence, choice and control. The role holders will work as part of a multi- disciplinary team in a person-centred way, proactively seeking to empower people and maximising their potential for independence.

This may include working with people with a frailty; people with physical impairments; people with mental, sensory, cognitive impairments; people with a learning disability; and supporting End of Life care.

The role holder will be required to work flexibly, supported with mobile IT equipment and hot desk facilities.