High Intensity Use (HIU) Care CoordinatorNHS

Job summary

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.

Main duties of the job

Work with the High Intensity Use workforce and stakeholders across the healthcare system to implement referral and feedback processes.

Develop comprehensive knowledge of wider support services for people with high support needs, including social isolation, wellbeing, housing, unemployment and welfare benefits.

Develop the directory of prescribed services and maintain systems for accurate HIU service delivery records.

Liaise with health professionals and build relationships with existing services to increase project visibility and ensure information remains current and relevant.

Support robust patient flow from referral through to outcomes for the HIU cohort.

Create tools to enable effective referral and client engagement, and implement a process for feedback to referrers.

Report risks and implement actions as directed by the line manager / NWL HIU Programme.

Work with healthcare IT systems to ensure appropriate referral and ongoing client management processes are established.

Arrange and coordinate administrative support for regular borough-based HIU multidisciplinary team meetings.

Support the HIU communication strategy to ensure stakeholders are informed and aware of the project and their roles.

Advocate for potential barriers and stigma affecting this vulnerable cohort, promoting equality, diversity and safeguarding across the service.

Job description

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

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 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 patient database

Engage with NWL 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 environment

Constantly strive for providing efficient, high quality care to identify underlying issues relating to demand and barriers for patients

Appropriately handle confidential and sensitive patient information

Determine links to existing projects, identifying interdependencies across projects/functions, potential impacts on wider organisation, resource requirements building in contingency as necessary

Where required, support the HIU workforce to produce tools and models for client engagement that address wellbeing, asset mapping, signposting, empowerment, and self-help

Monitoring, report and evaluation

Plan, develop and implement methods and processes with the HIU workforce, to support the evaluation of service demand and patient outcomes

Monitor and evaluate the effectiveness of the service against agreed targets

Support the development of quarterly and annual reports for the service, including information that demonstrates the qualitative and quantitative benefits delivered

Document any gaps in service provision for the High Intensity Use cohort

Drafting reports and summarising issues, patient outcomes, and providing progress reports for NWL HIU Programme (i.e. NWL Integrated Care Board)

About us

The London Medical Associates West London GP Federation (LMA) supports primary care across West London, delivering services across Kensington and Chelsea and Paddington and Queens Park in Westminster.

Our teams work with our Board, five PCNs, patients and local partners to develop place-based initiatives that integrate services and improve population health.

This role is a key pivot within the High Intensity Use (HIU) programme, working across organisational boundaries to strengthen pathways and improve outcomes for people with high support needs. A significant part of the role involves working with acute trusts, particularly Chelsea and Westminster Hospital NHS Foundation Trust, alongside primary care, community services, local authorities, voluntary and community organisations and other partners.

The post will develop referral and feedback mechanisms, support patient flow and connect people with appropriate health, social and wider support services. It will build stakeholder relationships, increase HIU visibility and ensure pathways remain current and effective.

The role will maintain the HIU service directory and records, create referral and engagement tools, coordinate HIU multidisciplinary meetings and work with healthcare IT systems to support referral and client management.

The post will support communications, report risks and advocate for people experiencing barriers and stigma, promoting equality, diversity and safeguarding across the service.