Care Co-ordinator

3 weeks ago

Harrow, United Kingdom Harrow Carers Full time

**HOURS PER WEEK: 37.5**

**DURATION: Fixed term till December 2025**

**1.0 JOB PURPOSE**:
The post holder will be responsible for the supporting the delivery of the High Intensity Use service in the community. The role will require engagement with clinical staff to coordinate care for individuals referred and identified by the service. The aim of the service will be to provide positive health and well-being outcomes, through addressing non-medical/social issues in their life, such as housing, debt or isolation.

The post holder is responsible for facilitating discussions between Primary Care, hospital and community services. The post holder will be required to manage patient caseloads and advise on improvements, which will be used to deliver measurable outcomes for the benefit of patients, staff and the public. The role requires extensive liaison with statutory and non-statutory services, to review and support the flow of referrals into the service. The main focus client groups include individuals experiencing homelessness, mental health and medical, social presentations, who may not be accessing scheduled services and therefore relying heavily on unscheduled services.

**2.0 REPORTING STRUCTURE**:
This role will support the High Intensity User scheme and be accountable to the Primary Care/Community Directorate management structure.

**3.0 Key working relationships**:
**Service set-up alignment**
- Work with the High Intensity Use workforce and stakeholders across the healthcare system to implement referral and feedback mechanisms
- Develop a comprehensive knowledge of wider support services for people with high support needs including; social isolation, wellbeing, housing, unemployment, welfare benefits.
- Extend and develop the menu of services prescribed in the form of a directory, and develop and maintain systems to keep accurate records relating to the delivery of HIU service
- Liaise with health professionals and establish relationships with existing services, to increase visibility of the project and to ensure information is up-to-date and relevant
- Support a robust patient flow process from referral to delivery of outcomes for the HIU cohort
- To create appropriate tools that enable effective referral and client engagement. Develop and implement a process to give feedback to referrers
- Report risks and implement actions as directed by the line manager /NWL HIU Programme
- To work with healthcare IT systems to ensure appropriate referral and ongoing client management processes are put in place
- To arrange, and coordinate administrative support for the service’s regular borough-based HIU multidisciplinary team meetings
- Support the communication strategy for HIU services to ensure all stakeholders are informed and aware of the project and their roles within it
- Be an advocate for potential barriers and stigma associated with this vulnerable cohort to promote equality, diversity and safeguarding service-wide

**4.0 KEY RESULTS AREAS**

**Key partners and communication**
- Develop excellent working relationships with the all partners, wider service networks

including the High Intensity Use service teams, voluntary sector, GP practices, adult social care, hospitals, community pharmacists and other members of the MDT and the NWL HIU Programme
- Build and maintain effective relationships with Information, Advice and Guidance Services
- Share learnings from the project with community based staff to promote safe practice and sustainability
- Maintain good communication with clients and, where appropriate, their families/carers
- Present highly complex information about the project, initiatives and service providers to a wide range of stakeholders in a formal setting
- To produce marketing materials, attend event and outreach where necessary to promote the service
- Is able to recognise personal limitations and refer to more appropriate colleague(s) when necessary

**5.0 SERVICE DELIVERY**
- Work with commissioner colleagues and the wider HIU staff workforce, to support a review of local demand for this cohort (i.e. Primary Care and A&E services)
- Act as the central point of contact for all referrals to the High Intensity User community/Primary Care HIU service aspect
- Provide information, advice and guidance to referred stakeholders including signposting where appropriate
- Support clinical staff to develop and upload personalised plans with clients to IT systems (i.e. Universal Care Plans, personalised care plans)
- Develop and maintain a client database
- Engage with Harrow GP practices and Primary Care Networks on a regular basis
- To monitor developments within Primary Care and for HIU services at a national-level and to ensure that this is fed in, where possible to local activity.
- Adhere to all relevant internal policies and procedures and ensure compliance with data Protection, Health and safety and safeguarding policy and best practice
- To operate in a highly political and sensitive env

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