Care Navigator

2 weeks ago

Nottingham, United Kingdom Nottingham CityCare Partnership CIC Full time

To receive referral information from members of the PCNs neighbourhood (Multi-Disciplinary) team, co-ordinating the appropriate response based on clinical / presenting need within the agreed pathways to the most appropriate service/s To make judgments regarding referrals, using triage protocols to ensure that citizens are seen by the most appropriate team / service at the right time to meet their needs. Whilst recognizing the need to involve, or seek advice from, more experienced colleagues as necessary for clinical decision making To be responsible for the co-ordination and to liaise with all relevant statutory and voluntary sector services including the local authority responsible for the patients care to arrange the necessary support To be responsible for tracking citizens through health and social care to ensure a smooth hand over to a named care manager / service To become a self-care champion and support the clinical teams around self-care issues, including social prescribing To identify care gaps resulting in interventions much earlier in the patients journey to prevent re-admission into hospital Neighbourhood team MDT Meetings Be responsible for facilitating regular (monthly as a minimum) multidisciplinary team meetings for each practice within the nominated PCN Be responsible for arranging, attending and minuting the neighbourhood (MDT) meeting and compiling agendas and undertaking associated administrative work and initiating referrals within agreed format / process where appropriate following the discussions. All cases on the list will be reviewed and decisions logged on the risk of admissions register Data management To support the proactive identification of citizens at high risk of admission / loss of independence as part of the neighbourhood team. Be responsible for the monitoring of acute and respite / residential admissions and to update data recording systems and clinicians / practitioners where appropriate.

To contribute to the integration of health and social care by maintaining up to date recording systems for all agencies within the neighbourhood (MDT) team and providing information to any member of the neighbourhood team in order to ease processes and communication in agreement with data protection protocol To be responsible for recording, reporting and producing evaluation reports which will include evaluation detailing effectiveness outcomes of new roles. To receive, breakdown and co-ordinate data and produce spread sheets for analysis (which shall include identification of referral trends and geographical spread of referrals and interventions to support the delivery of care within the PCN) To record citizen interventions on relevant electronic database systems (e.g. SystmOne and Liquid Logic ) and contribute to report generation, analysis and production

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