Neighbourhood Case Manager

Job overview

We are recruiting passionate and proactive Neighbourhood Case Managers to join the Hertsmere Neighbourhood Proactive Care Service. This is an exciting part time opportunity (26.25 hrs per week) to play a key role in a new team delivering community-based, person-centred care for residents. The focus will be on holistic assessments, care coordination, addressing health inequalities and delivering on the strategic ambition of a 'neighbourhood health service’.

You'll work as part of a multidisciplinary team supporting a cohort of residents with moderate to severe frailty who have had 2 or more unplanned admissions within the last year, linking them to health, social care, and voluntary sector services.

This service will see the shift from reactive care to proactive identification by using risk stratification searches within Primary Care records. The searches will identify a cohort of patients who would benefit from targeted intervention to improve outcomes, their overall experience and reduce the likelihood of further unplanned admissions. The service will operate alongside a number of acute and community services, with the ability to step patients up into appropriate services - including the highly successful virtual ward models in South and West Hertfordshire.

As this is a community-based role, there is a requirement to hold a full, valid, UK driving licence and have access to a car to use for business purposes (unless you have a disability as defined by the Equality Act 2010).

Main duties of the job

The post holder will be responsible for:

Overseeing care provided in the Proactive Anticipatory Care Service. This will include line management of the Neighbourhood case coordinator, ensuring proportionate and holistic patient assessment is completed, developing integrated care plans which anticipate potential future needs, using an effective multidisciplinary platform for discussion of complex cases, and maximising the value added by the role of senior clinicians.

This will include:

• Provision of a proactive, personalised and multidisciplinary case management approach to “high risk” patients identified through a risk stratification search in the Neighbourhood. This includes those with end stage disease who are approaching end of life, have moderate to severe frailty or dementia and have had 2 or more unplanned hospital admissions.
• Facilitation of timely, effective, and purposeful multidisciplinary discussion and decision making, resulting in coordinated and integrated care plans which can effectively anticipate and respond to changing patient needs.
• Undertaking comprehensive assessment of complex care needs using tools and templates available within the electronic clinical record.

This role presents as an excellent opportunity to work in a topical area of service delivery within the NHS right now and will provide the opportunity to gain service development skills.

Detailed job description and main responsibilities

Applicants are expected to present clear and relevant evidence of the competencies and responsibilities detailed in the attached Job Description and Person Specification, together with a demonstrated commitment to the Trust’s values of Accountability, Inclusion, Compassion, and Empowerment.

**Please see attached Job Description and Person Specification for full roles and responsibilities.**

Applicant requirements

You must have appropriate UK professional registration.

This post is subject to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2020 and it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service.