Integrated Care Lead

We Listen, We Learn, We Lead Contribute to, support and promote ECCHs, strategic direction, values and culture in relation to Reactive services. Discuss all treatment options with sensitivity, knowledge and expertise and to act as a patient advocate when appropriate, respecting patient confidentiality with privacy and respect for diverse cultural backgrounds and requirements. Understand and support the achievement of ECCH business plan objectives and performance targets for team and self, and initiate and participate in screening and needs assessment as required. Identify the potential for service developments, risk and deficits and inform line manager making recommendations based on specialist knowledge and experience.
Provide leadership and ensure effective management of integrated teams, including rehabilitation support workers and paramedic teams through identified and those providing a Reactive response. Plan and organise a range of complex integrated multidisciplinary coordination in a wide range of settings to ensure best practice is delivered across the designated area of responsibility and the wider community. Provide clinical leadership within the integrated care coordination team including Primary, Social Care, and all other provider organisations to ensure high standards of care to patients the avoidance of unnecessary admission to secondary care. Through effective leadership, planning and coordination; be a key enabler for establishing integrated care teams both practically and behaviourally.
Work with the Primary Care Home leadership team (Locality Leads) to design, implement and review pathways and guidelines to support health care professionals in establishing patients to access evidence-based therapies. Develop systems to monitor, evaluate and audit service quality in order to meet nationally and locally set targets and report to Locality governance groups. Effectively communicate at all levels of the organisation and wider stakeholder, including a variety of health professionals, users and carers, to provide the best health outcomes. Maintain high levels of performance for service area and ensure that goals and objectives are monitored effectively to ensure quality outcomes are developed and maintained.
Provide leadership and manage stakeholder relationships effectively within service area and ensure teams and individuals are supported when faced with opposition or when working under conditions or pressure. Identify potential service developments, risks and deficits and discuss with line manager, making recommendations based on expert knowledge to enhance the capacity and quality of community care. Monitor and maintain standards / provide benchmarking data within service area to allow comparison with other healthcare providers. Participate in teaching and clinical supervision with primary care home team and other provider staff as required.
Critically evaluate research findings, national guidelines and implement changes in clinical practice as appropriate. Signpost patients, families, and carers to tailored education programmes, advice and support that may precipitate symptoms of acute exacerbation of underlying conditions or illness and include lifestyle changes that would be advantageous to health. Be responsible for participating and maintaining a learning environment and maximise opportunities for education and development in the clinical area to enhance individual development and performance in the delivery of high standards of care. My Accountability, My Responsibility Take responsibility for own personal and professional development; maintain competence, knowledge and skills commensurate with role.
Using a standardised approach but with a high degree of professional autonomy and accountability, work with Health, Social Care, Voluntary and other health providers and agencies, to provide patients with complex needs a single plan of care co-produced with the patient. Responsible for ensuring effective patient/case tracking within the local health system; provide baseline health data for receiving teams to support integrated, coordinated care. To include facilitation of Community Led discharge processes. As Care Coordination Lead, ensure high visibility and be accessible to patients, families and carers and be seen as being in charge of their care.
Use assessment tools/skills that will ensure an appropriate level of nursing or therapeutic intervention so that patients who present with highly complex needs are timely referred to the appropriate specialist. Be wholly accountable for practice taking every reasonable opportunity to sustain and improve knowledge and professional competence and, ensure that all aspects of professional behaviour as required within professional code are followed at all times. Maintain legible, accurate and contemporaneous patient records in accordance with ECCH Policy; the Nursing and Midwifery Council and Health and Care Professionals Council standards for rec