Network Care Coordinator - Frailty Care Coordination MDT Pilot

Dyddiad hysbysebu:	08 Awst 2025
Cyflog:	£28,000.00 i £34,000.00 bob blwyddyn
Gwybodaeth ychwanegol am y cyflog:	£28000.00 - £34000.00 a year
Oriau:	Llawn Amser
Dyddiad cau:	17 Awst 2025
Lleoliad:	London, E14 0EY
Cwmni:	NHS Jobs
Math o swydd:	Cytundeb
Cyfeirnod swydd:	A2175-25-080825

Crynodeb

Key responsibilities of the post a) Identify residents who would benefit from a Proactive Care approach Coordinate the list of residents who fit the criteria of 65+, moderately frail, with COPD/CVD and are frequent hospital attendees and who could be supported by a Multidisciplinary Team (MDT) approach Put in place for each resident who fits the criteria a Personalised Care and Support Plan, using EMIS Cross-reference lists with relevant patient records (and other systems as appropriate) to gain an understanding of the different professionals involved in the care of the resident Work with the relevant practitioners to prioritise the cohort list Work closely with practitioners to develop an increased awareness of households and patients who may be vulnerable and in need of support b) Have discussions with residents focusing on what matters to them Contact the resident to explain the proactive care offer and invite involvement Carry out a holistic strengths-based assessment of need, and build trust Communicate with the frailty and long-term conditions team with regards to health outcomes or any further assessment required c. Be a core part of Network Team MDTs To act as a key member of the network MDT leading and supporting the development of effective meetings Organise and lead monthly locality frailty care coordination MDT meetings Attend Neighbourhood meeting as part of MDT i.e. frailty, COPD, CVD meetings Bring for discussion patients identified for the proactive care pathway to the MDT Work with practitioners to ensure that relevant professionals involved in the care and support of the individual are involved in MDT discussions where appropriate d. Coordinate support for the resident Support people in managing their needs Support people to take up training and employment, and to access appropriate benefits where eligible Assist people in accessing self-management education courses, or interventions that enable them to support their health and wellbeing Provide coordination and navigation for people and their carers across health and care services Signpost residents to frailty, COPD and CVD and other relevant health services Signpost and work with local authority team to support residents care needs and wider determinants of health (housing, blue badge, employment etc.) e. Good record keeping Maintain accurate, confidential and up-to-date documentation on residents, including patients EMIS records Keep MDT related information up to date (agenda, minutes, follow-up actions) Ensure safeguarding arrangements are in place to support those residents identified for support Maintain monitoring and reporting templates up to date f. Evaluate outcomes for individual residents Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing using relevant goals-based measures With the wider Neighbourhood, gather and collate information, evidence and anonymised stories, reporting on outcomes and activity. Ensure effective qualitative and quantitative monitoring and evaluation g. Leadership Opportunity to champion the delivery of proactive care within the Neighbourhood, through a successful programme implementation Opportunity to work closely with practices in coordinating residents if needed Attend management meetings to update progress and concerns relating to the proactive care programme when required h. Working with others Be an active member of the Neighbourhood team to build relationships with General Practice, adult community nursing, adult community therapies, mental health, adult social care and voluntary sector staff. Attend relevant service meetings, forums and contribute to continuous improvement of the Neighbourhood team i. Supervision and training Proactively engage in training and support made available and undertake appropriate training with the Personalised Care Institute