High Intensity Use Lead

Job description

Job responsibilities

The post holder will work as an employee of the NHS First Coastal Primary Care Network.

It will be First Coastal PCNs collective responsibility to lead to the transformation of culture, behaviours and attitudes of high intensity users of health care and changing the behaviour and wellbeing of the HIU client group. The post holders role is to contribute to the changes and role model the appropriate behaviours to influence others.

The post holder will act as high intensity use lead working with people with high intensity use of healthcare, through direct contact with the client group, seek to create a connection and discover and address any underlying reasons (social or emotional) that may be contributing to elevated health care contacts. This will deliver measurable improved outcomes for the benefit of clients, staff, and the community.

The main focus includes unmet social needs that present as medical or mental health episodes to A&E. Other reasons why HIU individuals attend healthcare more than expected include, homelessness, individuals who self-harm, and medical, social presentations. They may not be accessing scheduled services and therefore rely heavily on unscheduled services. The ability to connect with others is pivotal to this role, actively listening and working together to underpin changes the client needs support with rather than resorting to punitive measures.

Our key expectations of the HIU lead role are:

Self-awareness

Adaptability

Openness

Positivity with a real sense of being able to strive for the impossible

Generosity of spirit

Ability to negotiate with stakeholders as well as the client themselves

Job Summary

A highly motivated, emotionally intelligent, and resilient person with leadership skills, whose drive is quality client care and who thrives off innovation. Lateral thinking, which is out of the box is encouraged to support this vulnerable client group.

The Objectives of the Service are:

Measurable:

Identify those at greatest risk of A&E attendance and non-elective admissions.

Proactively work with a rolling cohort of HIU clients, really understanding what they need.

To coordinate wellbeing and connect with other services, enrolling them to help to get to the desired end.

Reducing 999 calls as a natural by-product (possibly ambulance and police).

Reducing A&E attendances and avoidable non-elective admissions

More Difficult to Measure but Essential:

Drive equality and client voice.

Forming robust network of community health, social care, mental health and police to manage clients, creating true integrated working.

Providing a service driven by quality with positive human outcomes observed.

Act as a conduit to negotiate and de-escalate issues before a crisis occurs; a situation which has historically led to a destabilisation of their condition and resulting in a A&E attendance/999 calls.

Improving communication and partnership working between those involved in client care 24/7.

Identify patterns and causal factors which trigger relapse behaviours in order to shape future commissioning of service and/or demand/capacity planning.

Empower clients to self-manage to enable sustainable discharge.

Expected Outcomes:

The key outcomes that the proposed service will deliver are:

Impact positively on reducing the high intensity use of healthcare.

To support clients to flourish through sustaining job opportunities, reconnecting with families, improving well-being etc.

A new culture of 1:1 coaching as a medium to deliver sustainable change.

It is recognised that the latter two points of expected outcomes are more difficult to measure but they are essential outcomes if a culture change is to occur to lower the stigma associated with this cohort.

The post holder is responsible for creating an innovative way of supporting the reduction in high intensity use of A&E. They will facilitate discussions and advise colleagues as to how best practice might be adopted for future development of the service and oversee their delivery.

Lead in removing potential barriers and stigma associated with HIU to promote equality, diversity and safeguarding service wide.

The HIU link worker will act as an advocate for the client, guiding them through the complex journey and multi-faceted approach to encourage appropriate use of scheduled and unscheduled care services.

A further element of the role would be coordination, sharing and learning of the work with community-based staff to promote safe practice and sustainability.

The post is responsible for providing professional expertise to the outcome of the business processes for the Lincolnshire Integrated Commissioning Board, including report writing and presenting evaluation reports.

Main Purpose of Job:

To provide holistic one-to-one-person centred support for people aged 18 & over who have high dependency on emergency services and who are frequent visitors/callers of A&E, the Urgent Care Centre and East Midlands Ambulance Service.

To meet and collaborate with identified MDT partners to identify, discuss, and prioritise appropriate referrals from the patient cohort list.

To work and collaborate with the voluntary and community sector, including Community Connector and wider Partnerships, to help identify appropriate referral destinations and to explore opportunities to meet gaps in services and activities.

To ensure effective record keeping and storage of patient data to demonstrate outputs and outcomes which is compliant with GDPR.

To actively contribute as a member of a well-established social prescribing team and PCN team advocating a neighbourhood working approach, with services who support the most vulnerable in society, contributing to the response to Population Health Management and Health Inequalities.

Key Tasks and Responsibilities

1. To provide holistic one to one social prescribing person centred support for people aged 18 and over who have high dependency on emergency services and who are frequent visitors/ callers of A&E, the Urgent Care Centre and East Midlands Ambulance Service.

Carry out the role of a facilitator, broker, sign poster, community connector and navigator, acting as an enabler between the voluntary and community sector, patients, GPs and health clinicians, and social care.

Provide support to patients, generally in their own homes, up to 3-4 months to help direct and connect them to alternative sources of non-medical support services and activities.

Offer a personalised approach to sensitively uncover the real reasons for them calling 999 or presenting frequently at A&E/UCC.

During client visits undertake an assessment to gather baseline data and to identify the support needs and actions. Generating personalised care and support or wellbeing plans, which may include risk management.

Ensure support actions agreed with the patient are carried out by the service. Support areas could include making referrals into a range of services provided by the voluntary, statutory or private sector, help with non-means tested benefit form filling e.g. Personal Independent Payments, Attendance Allowance, housing forms etc, distributing food bank vouchers, identifying suitable volunteering opportunities, connecting people into peer to peer led activities, initially taking patients to services if their confidence is low etc.

Once support has been provided carry out a final assessment

2. To meet and collaborate with A&E clinical staff regularly, to discuss, identify and agree appropriate referrals from the patient cohort list (patients presenting more than 12 times per year) and other patients presenting less than 12 times per year at A&E.

Meet with a range of health clinicians to discuss and agree appropriate referrals from the patient cohort list.

Build and maintain positive relationships with a range of health professionals.

Work closely with health clinicians to facilitate optimal joint working on safe and effective care for patients with complex needs.

Raise awareness of voluntary and community sector activities and services on offer to showcase the diverse range of services available to health and social care practitioners.

Raise awareness of the social prescribing and health and wellbeing service with health practitioners.

With health professionals and a range of providers identify service needs, broker solutions and when required enable individuals to be supported to kick start/lead on new activities through Lincolnshire CVS.

3. To work and collaborate with the voluntary and community sector to help identify appropriate referral destinations and to explore opportunities to meet gaps in services and activities.

Keep abreast of a wide range of support services on offer in the voluntary and community sector through undertaking research, making connections with organisations and groups and by using a range of local online directories and Community Connectors.

Build and maintain positive relationships with a wide range of voluntary and community sector providers.

When gaps in services and activities are identified discuss and raise these with the team and if required liaise with voluntary organisations and Community Connector to help identify solutions.

4. To ensure effective record keeping and storage of patient data to demonstrate outputs and outcomes which is compliant with GDPR.

Ensure all patient records and actions are entered onto our record keeping systems.

Ensure GDPR requirements are adhered to in relation to data management.

When required, support in gathering any data required for working out cost savings to the wider health and social care sector as a result of the service interventions.

5. To actively contribute as a member of a well-established social prescribing and PCN team who support the most vulnerable in society.

Actively contribute to team meetings, away days, planning activities and reflective practice activities.

Share progress, learning and challenges within the existing Integrated Plus social prescribing team.

Adhere to all Lincolnshire CVS, Integrated Plus policies and procedures.

Person Specification

Qualifications

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Experience

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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.

Employer details

Employer name

First Coastal PCN

Address

Marisco Medical Practice

Stanley Avenue

MABLETHORPE

Lincolnshire

LN12 1DP

https://www.mariscomedicalpractice.com/