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Integrated Neighbourhood Team Coordinator

4 months ago

Bury St Edmunds, United Kingdom West Suffolk NHS Foundation Trust Full time

**JOB PURPOSE**: The post holder will be part of a virtual team of health and social care staff. As a neighbourhood team coordinator you will provide data, co-ordination, support to clinicians and administrative support to multi-disciplinary teams of health and social services; this is within a defined locality in order to improve joint working practices leading to more effective patient care. As part of this role you will take on the administrative management of coordinating the care and multidisciplinary home visits for an enhanced community support offer. The post holder will help facilitate the integration of health and social care by maintaining up to date recording systems for organisations and by providing information to any member of the multi-disciplinary team in order to ease processes and communication in agreement with data protection protocol.

To work with multi-disciplinary databases and co-ordinate the information generated to inform users and commissioners about interventions and outcomes of the integrated care service. KEY TASKS: You will be required to work shifts between the hours of 8am-8pm, although the majority of the workload will be within core working hours. You will also be required to contribute to the coordination of the multi-disciplinary organisation as well as the delivery of health and social care plans for people who are newly discharged from hospital, discharged from a community assessment bed or who need support within their current home to prevent unnecessary admission. Tasks will, under delegation, include care coordination, information and data coordination and effective communication.

This involves working with all health and social care professionals, as well as statutory/non statutory agencies, to provide a seamless, integrated service to our service users. You will be required to work flexibly between the acute and community sites as the role dictates; own transport will be needed for this. Key Areas of Responsibility Integrated Care Co-ordination To process and case find referrals using coordination links within the whole system To coordinate the care and multi-disciplinary involvement of those people being treated/managed under the Integrated Neighbourhood Team enhanced care. To facilitate members of the multidisciplinary team (MDT) to meet on a regular basis, attend the meetings and ensure that the relevant people are invited.

Circulate relevant information prior to the MDTs, prepare agendas, ensure notes and any actions are taken and circulated to the relevant people. To take referrals from the MDT meetings within agreed format/process and act as a point of contact for health and social care professionals. To actively communicate (both face to face and remotely) with the acute hospitals to support admission avoidance and help enable appropriate timely discharges. To monitor daily hospital and respite/residential admission and to update data recording systems and clinicians/practitioners where appropriate.

To be a key administrative facilitator of patient admission to and discharge from enhanced care using agreed processes. To ensure the right services are in the right place at the right time by working with key MDT members. To promote and facilitate integration within the locality by improving communication links between services. To coordinate closely with the acute discharge planning and community assessment bed teams to support early suFpported discharge.

To act as a central point of information and a guide to processes for both health and social care services in the localities to improve working practices. To give information to and redirect to other agencies or individuals for those whose needs might be more suitably met elsewhere. To act as a resource and assist other staff with information on available resources, relevant organisations to be approached. Arrange, attend and minute meetings, compiling agendas and undertaking associated administrative work and follow up action, including ensuring professional staff are aware of referrals.

To be able to order equipment from the localities health and social care budgets Coordination and technical support to the INTs for the use of telehealth. Support telehealth set up and removal and troubleshoot telehealth problems, this may require home visits. Support MDT with delivery of equipment and medication as prescribed by clinician Information and Data Co-ordination To receive, breakdown and co-ordinate data and produce spreadsheets for analysis and costing within set criterias. To identify pathways and geographical spread of referrals and interventions.

To present findings at multi-disciplinary team meetings. To maintain accurate databases and spreadsheets in order to provide up to date information to any of the multi-disciplinary team about any individual in order to ease processes and communication. Collect and cascade information on unplanned admissions and attendances to acute hospitals using a set crite