Proactive Care Practitioner inCamberley inCamberley PUBLISHED TUE 19 NOV 2024

Depending on experience Band 6 or Band 7 PERMANENT
HOLISTIC

Surrey Heath Community Providers Ltd rrP0enMe

The Proactive Care Practitioner role at Surrey Heath Community Providers Ltd in Camberley involves delivering a responsive and effective care service tailored for individuals experiencing mild to moderate frailty and long-term conditions. The practitioner will conduct comprehensive assessments and implement proactive case management through shared decision-making, encouraging self-management, and providing referrals as necessary. This position requires collaboration with Integrated Care Teams, local GP practices, and the Frailty MDT, as well as travel to various locations within the Surrey Heath area.

In this role, practitioners will assess patients with a range of acute and chronic conditions, creating personalized care plans that incorporate evidence-based practices and a holistic approach, such as comprehensive geriatric assessment. They will focus on identifying target patient cohorts who would benefit most from proactive care to improve health outcomes, ensuring effective communication and care pathways with other agencies involved in patient support.

The Proactive Care Practitioner will provide a responsive, safe, effective caring Proactive Care service. The service aims to support an identified cohorts of people living with mild to moderate frailty and long term conditions, providing comprehensive assessment and proactive case management.

This will include adopting a shared decision making approach and supporting self-management through sign-posting, health coaching and social prescribing, MDT discussion and onward referral as required.

The Proactive Care service, whilst operating from a local hub, will require travel to Practices or patients homes across the Surrey Heath PCN geography.

To work closely with the Integrated Care Team, Frailty MDT and local GP teams to provide proactive care services for patients with frailty or those with a long term condition identified as requiring an anticipatory approach.

To support the identification of the target cohort for whom there is the greatest potential impact on health and system outcomes.

To provide specialist assessment of patients, using analytical and judgment skills. To provide appropriate patient centred treatment using evidence based practice where-ever possible. Patients will present with acute or chronic conditions and complex multi-system pathologies e.g. neuro, respiratory conditions, orthopaedic rehabilitation and age related deterioration.

To ensure holistic assessment using an agreed approach, such as comprehensive geriatric assessment (CGA).

To devise effective personalised care plans for each patient with specific therapeutic knowledge, recognising him or her as an individual. The plan of care, which has been developed in conjunction with the patient, carer and relevant others, should be outcome based and ensure appropriate pathways of care and communication via liaison and referral to other agencies as required.