Job responsibilities
Job Summary
The role holder will provide a
practical front-line support service, using assessments to identify and develop
care and support plan(s) to meet the assessed needs of people accessing the
locality hub, in partnership with professional staff in other agencies and
service providers. They will help people with information, advice and guidance;
and work as necessary with the multi-disciplinary team and community to ensure
provision of support for people accessing the locality hub.
This may include working with people
with a frailty; people with physical impairments; people with mental, sensory,
cognitive impairments; people with a learning disability; and supporting End of
Life care. They will work within the multi-disciplinary team under the
supervision and guidance of the senior hub leadership.
The post holder will be responsible
for the coordination of care and support to patients
supporting them from the point of
referral. The Hub Coordinator ensures that patients who are supported
through the service are supported in the right place, by the right
person, at the right time.
The post holder will facilitate the
delivery of high levels of patient care and will ensure that patients and
clinicians have a good experience by being an accessible, customer focused and knowledgeable point of contact.
They will develop and maintain an
understanding of the work being done outside of the hub (including voluntary
organisations and community resources), to have a good working knowledge and
relationship with those services. These interrelationships are crucial to the
success of finding creative solutions and services, to ensure independence,
choice and control. The role holders will work as part of a multi-disciplinary
team in a person-centered way, proactively seeking to empower people and
maximizing their potential for independence.
The role holder will be required to work
flexibly, supported with a mobile, I.T. equipment and hot desk facilities.
A valid UK driving licence and access to a vehicle which can be used for work purposes is essential.
Main Duties and Responsibilities
To work as part of the Community Hub ensuring
that people who are supported
through the service are guided
through their required pathway efficiently. Referrals could include making
arrangements for home
visits, assessments, referral
for diagnostic procedures
or admission for a limited time or referral onto other
disciplines such as
health or social
care or voluntary services.
Following initial triage, the role holder will
be the point of contact with the service, gathering initial information,
providing guidance, initiating and carrying out assessments, as well as
signposting them to other services. This range of providers will include
District and Borough Councils, Family, Friends and Community Support, and other
agencies including but not limited to NHS Continuing Healthcare, Carers support
groups, and Charities.
Create, monitor, manage and coordinate
multi-disciplinary care, support plans for people which are Care Act compliant
and meet their needs in line with partner organisations.
Engage effectively with people and their
families to facilitate contingency planning to anticipate complexity and
changing circumstances. Ensure proportionate reviews are completed so that
people have the opportunity to reflect on what is working, and what needs to be
changed, and can do so in a person-centred, outcome-focused way.
Ensure that independent advocacy services are
utilised when required to enable engagement in the assessment process.
Attend meetings as part of the Community Hub
Team across North West Surrey as required.
To coordinate and book appointments, including
transport, as required.
To attend multi-disciplinary team meetings both
inside and outside of the Hub, including GP practices and other organisations
where appropriate.
To ensure that the information on the
individuals records is recorded accurately and
comprehensively on the patient information systems (RIO, EMIS or other).
Check
patient identity details
including all demographic information
during patient encounters.
Ensure that information distributed to people to
be supported by the team is accurate and current.
Be pro-active, establish and maintain
regular contact with
people identified as at risk
of admission to hospital to facilitate
such people to
remain at home.
If they experience deterioration in their condition
such people will be escalated to the relevant health or social care colleagues,
dependent on their care plan.
To act as a key point of contact and provide
a central point
of contact for
people to be supported by the service and the range of
professionals involved in their care.
Assist in development and project work, and work
with other staff to provide information and feedback. For example, hub
promotional events or information sharing events.
As the first point of contact liaise with
partner organisations to assist in the assessment and
provision of care of people to be supported through the service.
This includes liaison with primary, secondary,
social and tertiary care providers ensuring that information is recorded and/or
provided at the point of receipt of referral.
Assist the wider
community hub team in
sourcing and delivering care and
support i.e. home based care, Community Hospitals, residential
and nursing care, respite care, support through voluntary organisations and
support for carers to be able
to offer local
knowledge of the
range of health and social care
services available for people to be supported by the service.
Be aware of the needs and concerns of people who
can be supported through this service and provide a friendly, efficient and
courteous service to patients, relatives and visitors, providing them with
advice and information as appropriate. Use empathetic approach to patients
and/or relatives seeking assistance from clinical staff/senior managers as
appropriate.
Identify and manage risk associated with open
cases to ensure safeguarding of people on the caseload. Make use of line
manager/supervisor to escalate risks when necessary.
Conduct standard assessments of service users
circumstances and issues, recommending onward referrals, to ensure protection
of vulnerable individuals.
Provide caseload management as allocated by
senior colleagues, working within guidelines and
procedures, and record the
individuals progress.
Support people to access community opportunities
and work directly with users, providing advice and support to facilitate
independence.
Plan, organise and supervise allocated
activities within procedural and regulatory framework. Typically deal with
multiple cases and/or groups at one time.
Assist in the induction of new colleagues by
sharing expertise and knowledge within the team.
