Job description

Job responsibilities

• Coordinating a defined caseload of patients with long-term conditions, frailty and complex health and social care needs under the guidance of the multidisciplinary team.
• Supporting the coordination of care across health, social care and voluntary sector services to ensure seamless, person-centred care delivery.
• Assisting patients to maintain their independence and wellbeing through proactive care coordination, personalised support and timely interventions.
• Supporting the development, implementation and review of personalised care and support plans in partnership with patients, carers and the wider multidisciplinary team.
• Providing information, advice and signposting to appropriate health, social care and community services to help patients access the support they need.
• Promoting person-centred care and supporting patients to make informed decisions about their health and wellbeing.
• Supporting proactive identification of patients who may benefit from coordinated care and early intervention, contributing to population health management initiatives and reducing avoidable hospital admissions.
• Participating in population health activities, health promotion initiatives and public health events across the Integrated Care Community (ICC), supporting the delivery of preventative care and improving health outcomes within local communities.
• Monitoring patient progress, maintaining accurate and timely clinical records, and escalating changes in patient needs or identified risks to the appropriate clinician.
• Developing effective working relationships with colleagues across primary care, community services, acute care, social care and the voluntary, community, faith and social enterprise (VCFSE) sector to support integrated, coordinated care.
• Providing day-to-day support and guidance to Band 4 Care Navigators, promoting effective team working, sharing knowledge and contributing to the smooth running of the service within the scope of the role.
• Supporting the Case Managers by undertaking delegated activities and, where appropriate, providing operational support and coordination during periods of planned or unplanned absence to ensure continuity of patient care and service delivery.
• Contributing to service improvement initiatives and the continued development of Barrow ICC, whilst actively participating in learning, reflective practice and ongoing professional development.

Person Specification

Qualifications

Essential

• Registered Nurse (Adult) or Registered Mental Health Nurse (RMN), registered with the Nursing and Midwifery Council (NMC) or HCPC-registered Allied Health Professional
• Experience working in a community, primary care, integrated care or multidisciplinary team. Experience supporting patients with long-term conditions, frailty or complex health and social care needs. Experience of coordinating care and working collaboratively across services.
• Understanding of person-centred care, Safeguarding, Mental Capacity Act, confidentiality and information governance. Knowledge of community services and integrated working. Understanding of care planning and holistic assessment.
• Excellent communication and interpersonal skills. Ability to build effective relationships with patients, carers and professionals. Good organisational and time management skills. Ability to prioritise workload and manage a caseload. Competent IT skills, including electronic patient record systems and Microsoft Office. Ability to work independently and within a multidisciplinary team.
• Ability to travel independently across the ICC footprint. Full UK driving licence and access to a vehicle (where required). Willingness to undertake relevant training and continuing professional development.

Desirable

• Mentorship/practice assessor qualification; relevant post-registration modules (e.g. long-term conditions, frailty, health coaching).
• Experience using EMIS, SystmOne or other clinical systems. Audit and data collection skills. Presentation or teaching skills.
• Experience within an Integrated Care Community (ICC), Primary Care Network (PCN) or Community MDT. Experience of discharge planning, case management support or care coordination. Experience of population health or health promotion initiatives.

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).

Employer details

Employer name

University Hospitals of Morecambe Bay NHS Trust

Address

Barrow ICC, Fair Field Lane

Barrow in Furness

LA13 9AH

United Kingdom

Employer's website

https://www.uhmb.nhs.uk (Opens in a new tab)