Job summary
The
Proactive Care Practitioner will provide a responsive, safe, effective caring Proactive
Care service. The service aims to
support an identified cohorts of people living with mild to moderate frailty
and long term conditions, providing comprehensive assessment and proactive case
management.
This
will include adopting a shared decision making approach and supporting
self-management through sign-posting, health coaching and social prescribing,
MDT discussion and onward referral as required.
The
Proactive Care service, whilst operating from a local hub, will require travel
to Practices or patients homes across the Surrey Heath PCN geography.
Main duties of the job
To work closely with the Integrated Care Team,
Frailty MDT and local GP teams to provide proactive care services for patients
with frailty or those with a long term condition identified as requiring an
anticipatory approach.
To support the identification of the target cohort
for whom there is the greatest potential impact on health and system outcomes.
To provide specialist assessment of patients, using
analytical and judgment skills. To provide appropriate patient centred
treatment using evidence based practice where-ever possible. Patients will
present with acute or chronic conditions and complex multi-system pathologies
e.g. neuro, respiratory conditions, orthopaedic rehabilitation and age related
deterioration.
To ensure holistic assessment using an agreed
approach, such as comprehensive geriatric assessment (CGA).
To devise effective personalised care plans for each
patient with specific therapeutic knowledge, recognising him or her as an
individual. The plan of care, which has been developed in conjunction with the
patient, carer and relevant others, should be outcome based and ensure
appropriate pathways of care and communication via liaison and referral to
other agencies as required.
About us
We
are Surrey Heath Community Providers Limited, which is a federation of 7 GP
practices across 10 sites, covering a population of over 103,000 patients
across Surrey Heath. We began in 2016 and now employ around 200 members of
staff across our head office sites, and our primary care and unplanned care
services.
As
a GP Federation, we are proud to represent our member practices and to champion
primary care by working with local general practice and system partners in the
provision of community-based healthcare services. We are dedicated to providing
safe and compassionate care to our patients across our range of primary care
and unplanned healthcare services in Surrey Heath, and believe in continuous
commitment to quality service delivery and positive patient outcomes.
Patients are at the heart of
everything we do, and we pride ourselves in ensuring our patients feel safe, supported,
communicated with and respected, at a time when they may be feeling
vulnerable. Our vision is to provide high quality, seamless health care that
enables people to lead healthier lives, whilst feeling supported and cared for.
Job description
Job responsibilities
Please refer to Supporting Documents for full Job Description, list of responsibilities and person specification.
Job description
Job responsibilities
Please refer to Supporting Documents for full Job Description, list of responsibilities and person specification.
Person Specification
Education, Training and Qualifications
Essential
- Maths and English GCSE'S (C and above) or equivalent.
- Registered Healthcare Professional, with either the NMC or HCPC.
- Degree level education.
- Post Registration qualification in relevant area.
- Teaching and assessing qualification.
Desirable
- Masters degree or equivalent experience gained by undertaking on-going personal development and training. Management/Leadership Qualification/development programme.
Experience
Essential
- Significant relevant experience in frailty and proactive long term condition management. Experience of caseload management including responsibility for complex assessment and management of vulnerable people. Participates in regular clinical supervision. Experience of working with long-term conditions and frailty.
Desirable
- Experience, underpinned by knowledge of working with and understanding the complex needs of patients in a primary care/community setting. Involved in the implementation and management of change. Evidence of innovative practice.
Knowledge and Understanding
Essential
- Good understanding of current nursing and AHP workforce issues. Clear understanding of Primary & Community health services. Demonstrates an understanding and insight into current issues and developments within the NHS.
Other
Essential
- Car driver with valid licence. Reliable and flexible. Ability to work well in stressful situations. Innovative and adaptable. Assertive. Commitment to attend forms or training as learning needs are identified.
Skills and Abilities
Essential
- Excellent written and verbal communication and interpersonal skills
- Enhanced clinical skills. Ability to advocate on patient issues. Ability to demonstrate leadership skills. Organisational and prioritisation skills: including the ability to make decisions and to prioritise. Ability to understand and interpret research findings/evidence based care and apply to practice. Good working knowledge of health and safety and risk management, including lone working. Computer literate including emails and spreadsheets.
Person Specification
Education, Training and Qualifications
Essential
- Maths and English GCSE'S (C and above) or equivalent.
- Registered Healthcare Professional, with either the NMC or HCPC.
- Degree level education.
- Post Registration qualification in relevant area.
- Teaching and assessing qualification.
Desirable
- Masters degree or equivalent experience gained by undertaking on-going personal development and training. Management/Leadership Qualification/development programme.
Experience
Essential
- Significant relevant experience in frailty and proactive long term condition management. Experience of caseload management including responsibility for complex assessment and management of vulnerable people. Participates in regular clinical supervision. Experience of working with long-term conditions and frailty.
Desirable
- Experience, underpinned by knowledge of working with and understanding the complex needs of patients in a primary care/community setting. Involved in the implementation and management of change. Evidence of innovative practice.
Knowledge and Understanding
Essential
- Good understanding of current nursing and AHP workforce issues. Clear understanding of Primary & Community health services. Demonstrates an understanding and insight into current issues and developments within the NHS.
Other
Essential
- Car driver with valid licence. Reliable and flexible. Ability to work well in stressful situations. Innovative and adaptable. Assertive. Commitment to attend forms or training as learning needs are identified.
Skills and Abilities
Essential
- Excellent written and verbal communication and interpersonal skills
- Enhanced clinical skills. Ability to advocate on patient issues. Ability to demonstrate leadership skills. Organisational and prioritisation skills: including the ability to make decisions and to prioritise. Ability to understand and interpret research findings/evidence based care and apply to practice. Good working knowledge of health and safety and risk management, including lone working. Computer literate including emails and spreadsheets.
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
Additional information
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
