Neighbourhood Care Coordinator

Job summary

Neighbourhood Working describes an integrated approach to managing patients, through a blended workforce that encompasses both health and social care; to include acute, voluntary and community sectors where barriers to working are negated, the health and wellbeing needs of the individual are at the centre of decision-making, care is proactive and not reactive, and services are provided in a timely manner. The Neighbourhood Coordinator will have overall responsibility for the coordination of the regular Multi-Disciplinary meetings and be responsible for personalised care planning and tracking patient caseloads. They will support a system approach, providing a responsive element to the front door of all South West Neighbourhoods. As part of the drive to improve care for service users and patients, there is a requirement for the post holder to work flexible hours. It is expected that cover will be provided across the working week (Monday to Friday) and during leave of absence by other post-holders in South West Lincolnshire.

Main duties of the job

• Provide direct support to patients and their carers to identify needs.
• Coordinate and manage administrative functions which will include ensuring that meetings are organised and recorded appropriately.
• Work closely, and communicate effectively with the local Primary Care network colleagues.
• Support peoples needs using population health management techniques and stratification to support proactive approaches in the community.
• Liaise with all professionals involved in the persons care including primary, secondary/emergency and community care services including mental health provision, carers, third sector organisations and other relevant groups.
• Identify opportunities to develop the neighbourhood, as well as blockers and inefficiencies in the system.
• Support local initiatives with partner organisations to widen the influence of the neighbourhood teams and to ensure local projects are co-ordinated across the area.
• To deal in a professional, helpful and effective manner with members of the neighbourhood, and outside agencies.
• To input data onto the patient information management system (SystemOne) to update patient records, including outcomes of reviews, planned interventions/assessments, patient details, and periodically use reports to ensure service user details are correct.
• Maintain a network of contacts with other Lincolnshire Neighbourhoods in order to share good practice and new ideas.

About us

K2 Healthcare is a GP federation constituted of 16 member GP Practices in South West Lincolnshire with two Primary Care Networks and supporting a population of 133,000 people.

K2 works together to share resources and expertise that enable practices to provide shared services and business systems to provide the best possible care for our population, ensure sustainability, growth and value for GP practices and system partners within available resources.

The Better Lives Lincolnshire Integrated Care System sees us working in a provider collaborative with the Primary Care Network Alliance, Secondary Care, Community Health, Mental Health, Social Care as well as Local Authorities, and the Community and Voluntary Sector.

How we do it is as important as what we do and relationships with our partners is at the core of everything we do.

Neighbourhood Working describes an integrated approach to managing patients, through a blended workforce that encompasses both health and social care; to include acute, voluntary and community sectors where barriers to working are negated, the health and wellbeing needs of the individual are at the centre of decision-making, care is proactive and not reactive, and services are provided in a timely manner.