Care Navigator

Are you passionate about patient care and want to make a difference to patients by navigating them through health & social systems

We are seeking to recruit 1 WTE Care Navigator for Bassetlaw. The role of Care Navigator is new to Bassetlaw; its a great opportunity for someone who is enthusiastic & passionate about patient care.

You will work collaboratively with primary care, community services, secondary care, social care and the voluntary sector (as appropriate and based on patient need). This will improve outcomes for patients and reduce healthcare costs.

The focus of the role is to identify and manage vulnerable patients (initially those with moderate and severe frailty and subsequently those living with long term conditions). This is fundamental to the delivery of the Integrated Care System (ICS) Frailty program. It is also fully aligned with the delivery of the ICS Integrated Care Strategy and NHS Joint Forward Plan addressing the specific needs of an ageing population and recognizing the economic and quality of life impacts of prioritizing frailty management.

Undertake daily identification of frailty and long-term condition workflows on E-Healthscope and decide the best course of action based on agreed Standard Operating Procedures (SOPs) and advice from clinicians/other key leads.

Proactively contact patients to complete the CFS and provide advice and refer to teams/services/local assets (where appropriate)

Undertake a holistic assessment/goal setting to ensure an advanced care plan is in place and agreed e.g. All About Me

Provide information to members of the PCN to aid communication

Complete relevant referral documentation and chase referrals as required and navigate and coordinate services to meet individuals needs across the PCN.

Access systems utilised across the ICS to support case analysis this includes but not limited to, Social Care, Mental Health and General Practice

Work closely with the integrated neighbourhood team for access to community-based activities

We are aprovider of NHS Community Health Services, City Care exists to support thehealth and wellbeing of all local people, working alongside other health andcare partners to achieve this. We are a value driven, people business with apassion for excellence. Our vision and social purpose is to make a difference everyday to the health & wellbeing of our communities and our values of kindness, respect, trust and honesty lie at the heart of everything we do,guiding how we work together with partners and each other to consistently deliver high quality compassionate care.

As a social enterprise we aim to addsocial value by investing in the future of our local communities and helping tomake a difference in peoples lives.

City Care valuethe benefits of a diverse and inclusive workforce. We encourage applications from candidates who identify as disabled, LGBT+ or from a Black, Asian or Minority Ethnic (BAME) background, as they are currently under-represented within our organisation.

We are proud to be a forces-friendly organisation and are dedicated to supporting Veterans, Service Leavers, Reservists, and military spouses/partners. We value the unique skills and contributions youbring.

City Care is anequal opportunities employer. We are positive about employing people with disabilities. If you require your application in a different format please contact People Services on . City Care is committed to the protection of vulnerable adults and children.

Job Purpose

To focus on the identification and management of vulnerable patients (initially those with moderate and severe frailty and subsequently those living with long term conditions). This refocus is fundamental to the delivery of the Integrated Care System (ICS) Frailty Programme.

To work in alignment with the delivery of the ICS Integrated Care Strategy and NHS Joint Forward Plan addressing the specific needs of an ageing population and recognizing the economic and quality of life impacts of prioritising frailty management

Dimensions

The post holder will work closely with Primary Networks (PCNs) acting as the named point of contact for information and a guide to processes for health and social care professionals within the PCN

The post holder will be accessible to patients members of the PCN via a dedicated telephone line between the hours of 8am and 6pm

Key Responsibilities

Undertake daily identification of frailty and long-term condition workflows on E-Healthscope and decide the best course of action based on agreed Standard Operating Procedures (SOPs) and advice from clinicians/other key leads.

Proactively contact patients to complete the CFS and provide advice and refer to teams/services/local assets (where appropriate)

Undertake a holistic assessment/goal setting to ensure an advanced care plan is in place and agreed e.g. All About Me

Provide information to members of the PCN to aid communication

Complete relevant referral documentation and chase referrals as required…