Proactive Care Lead, High Intensity Service Users

Job overview

Are you passionate about improving outcomes for people with complex health and social care needs? We are seeking an experienced and motivated Proactive Care Lead to identify, coordinate and support high intensity service users who frequently access healthcare services. You will work collaboratively across primary care, community, acute, mental health and voluntary sector partners to develop personalised care plans, reduce health inequalities, and promote independence. The successful candidate will demonstrate strong leadership, excellent communication skills, and a commitment to delivering person-centred care. This is an exciting opportunity to drive innovation, improve patient experience, and support sustainable healthcare delivery across the system.

A full UK driving license is essential for this post. Please note that an international driving license is not accepted.

Closing Date: Please be advised that this job advert will close as soon as sufficient applications have been received. Please apply for this job as soon as you can, if interested.

Secondment will be considered for internal candidates – If you are successful after interview, you must obtain approval from your current line manager to accept the offer.

Successful applicants will be required to provide an immunisation and vaccination report, from either their current UK occupational health provider or their UK GP.

Main duties of the job

• Proactively identify and support high intensity service users who frequently access acute, community, primary care, urgent and emergency care services, ensuring their needs are assessed holistically and managed through coordinated care planned.
• Undertake comprehensive assessments of individuals with complex health, social, psychological, and behavioural needs to understand the factors contributing to high service utilisation and identify opportunities for alternative approaches to care.
• Develop, implement, and regularly review personalised care and support plans that promote self-management, improve health outcomes, and reduce avoidable healthcare attendance and admissions.
• Work collaboratively with multidisciplinary teams, including acute, community, primary care, mental health, social care, and voluntary sector services, to coordinate appropriate interventions and ensure seamless care delivery.

Detailed job description and main responsibilities

• Proactively identify and support high intensity service users who frequently access acute, community, primary care, urgent and emergency care services, ensuring their needs are assessed holistically and managed through coordinated care planning.
• Undertake comprehensive assessments of individuals with complex health, social, psychological, and behavioural needs to understand the factors contributing to high service utilisation and identify opportunities for alternative approaches to care.
• Develop, implement, and regularly review personalised care and support plans that promote self-management, improve health outcomes, and reduce avoidable healthcare attendance and admissions.
• Work collaboratively with multidisciplinary teams, including acute, community, primary care, mental health, social care, and voluntary sector services, to coordinate appropriate interventions and ensure seamless care delivery.
• Act as a key point of contact for high intensity service users, providing case management, advocacy, and support to navigate services and access the most appropriate care pathways.
• Identify patients who may benefit from receiving care in alternative settings, such as community services, primary care, outpatient clinics, or other specialist support services, ensuring care is delivered in the most appropriate and least restrictive environment.
• Monitor patterns of service utilisation and identify trends, risks, and opportunities for intervention to improve patient outcomes and reduce unnecessary demand on healthcare services.
• Support the development and implementation of strategies, pathways, and initiatives aimed at improving care for high intensity service users, reducing health inequalities, and promoting integrated care across organisational boundaries.
• Maintain accurate records, collect relevant data, and contribute to service evaluation, quality improvement, and reporting requirements to demonstrate outcomes and inform future service development.
• Build effective relationships with patients, carers, families, and partner organisations to promote person-centred, coordinated care that improves patient experience and quality of life.

For further details of the role please see the attached job description.

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.