Salary Scale 21,909-28,462 Band 5. Central London Healthcare CIC

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Myrtle Lewis
5 years ago
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Job Title Care Navigator Salary Scale 21,909-28,462 Band 5 Accountable To Employer Based at Core Hours Service Manager Central London Healthcare CIC GP Practices within Village Structure The CCS core

1 Job Title Care Navigator Salary Scale 21,909-28,462 Band 5 Accountable To Employer Based at Core Hours Service Manager Central London Healthcare CIC GP Practices within Village Structure The CCS core hours are below: 09:00 17:00 (Monday Friday) If the core NHS service hours change in the future it is anticipated that these hours will need to reflect these changes. INTRODUCTION The Central London Care Coordination Service (CCS) encompasses identification, planning and coordination of care as part of a Whole Systems approach to providing care. The aim of the CCS is to improve the quality of care for people registered in GP practices within Central London by ensuring seamless pathways and proactive intervention where appropriate. JOB PURPOSE Care Navigators (CN) will be responsible for supporting GPs through providing care coordination for the whole population. This includes, for example, being responsible for intelligent tasking and patient referrals, booking of transport and equipment where required and delivering targeted public health messages to the full GP practice list. In addition, CN will work with the relevant agencies of the health and social care system to ensure coordinated and effective delivery of the patient s care plan for those patients identified through risk stratification by the GP. Each CN will be aligned to a GP Village within Central London, and may be required to work across several practices within the designate GP Village structure. Day-to-day work will be based in the relevant GP practices within the GP Village structure. The CN will also have access if required to the Care Coordination Centre, a central hub for all workforces within the Care Coordination service. Time spent in each GP practice may vary. In the Wave 1 Villages, CN will report to and have day to day supervision and support from the Clinical Coordinator based within the GP Village Structure. In all other villages overall line management and accountability will remain with the Service Manager. 1

2 ROLE SUMMARY CN will be responsible for providing support to their nominated GP Villages. Key functions of the role include: Care Planning Manage personalised care plans with the patients, helping them reach their goals of living healthy and living longer. Follow up and coordination. Ensures that actions from the care plans are followed up and coordinated to ensure they happen. Coordinating cases and single transaction patients. CN will be responsible for a named list of patients within SystmOne. Intelligent tasking. CN will signpost patients to services across the community. In a small percentage of cases this may constitute a formal service referral. Tasking may be assigned by the Senior Care Navigator or GPs for patients with more intensive needs. The Patient s Point of Access: The CN will provide proactive reminders and messages to suitable patients (such as COPD) alongside being an intelligent scheduler of multiple patient service appointments / interventions. Criteria based booking. Providing access to community services, which in more intensive cases may involve direct patient interaction. This will involve application of criteria framed decisions making about booking such things as equipment, interpreters and transport. Track and Trace. The CN will use the SystmOne clinical system to ensure it houses all relevant care plans and they are being followed to ensure service quality. Data Quality It is the CN responsibility to record the required data accurately into SystmOne for data collection, reporting and analysis. Participating in MDTs. Ensures relevant cases are referred to MDT. The frequency, attendance and method of the MDTs will be determined by each practice (within the frame of minimum standards set by the programme). Establishing and maintaining good relationships with members of the CCS and wider health and social care system. It is essential that the CN is skilled in communication and has a good grasp of the language of the health and social care system, to ensure the appropriate level of support is provided based on patients need. CN will work closely with the GPs in the practice(s) to which they are aligned, as well as the Senior Care Navigator in the CCS. MAIN DUTIES & RESPONSIBITLIES 2

3 Care Navigators will provide different services to patients, depending on their level of needs as identified by the GP. These are outlined below: 1. Tier 1 patients Manage personalised care plan for patients, identifying their goals Provide patients with helpful information and appointment availability Refer and discuss referrals with GPs to ensure that the most appropriate service is provided to patients, including proactive follow up on referrals Ensure patient record is kept up to date on the GP system Book patient appointments, and book transport where required Book equipment where required Book translators and other services where required Investigate and resolve complaints Monitors quality of patient care plans to capture and raise failures Provide targeted and proactive Public Health messages to the population 2. Tier 2-3 patients Attend MDT meetings to discuss identified patients with appropriate representation from a range of health and social care professionals, may refer patients Provide first point of contact for an identified list of patients Support GP appointments through: o Support GPs with admin work and log patient treatment history, updating Care Plan where necessary o Keep relevant Case Managers updated with the latest treatment information In addition to these, Care Navigators will be required to follow the policies and procedures set by Central London Healthcare CIC. They will also have a number of other duties, outlined below: Communication To establish excellent working relationships with all professionals involved across the local area and assist in the proactive management of the patient pathway To develop effective and collaborative relationships with members of the Villages and GP Practices To network and develop strong relationships with all levels of the NHS s key local players including GPs and other primary care contractors, Social Services, Mental Health Trusts, Community Trusts, and other providers including the voluntary sector To be a contact point for GPs / practices and establish systems and processes which will ensure a timely and appropriate response to queries from clinicians and other stakeholders To provide written and verbal reports as required To demonstrate an ability to convey complex information and ideas, both written and verbally Personal 3

4 Participate in an annual appraisal and maintain an up-to-date Personal Development Plan Participate in service development activities, identifying areas for improvement as appropriate Be aware of, and act in accordance with, Operational Policies Maintain appropriate and up-to-date knowledge and skills by undertaking continuing education in accordance with personal and service needs within the framework of a Personal Development Plan Initiative, Innovation and planning for service development. Attention to detail is key as accurate reporting is required Advocacy for Care Coordination and integrated care Equality and Diversity Support equality, value diversity and promote people s rights Respect and maintain patients/carer s privacy and dignity at all times Act in a non-discriminatory manner at all times Key Relationships Practice staff, including GPs, Practice Nurses Clinical Coordinator Care Administrators CCS Clinical Lead Community Nursing Teams Community Matrons Adult Social Services Mental Health services Specialist Nurses Statutory and voluntary agencies Statutory and Voluntary Sector Organisations Secondary Care Services including Discharge Teams And others, as and when required The list of duties and responsibilities is not exhaustive and will develop based on the needs and requirements of the practice, patient and Care Coordination Service. Care Navigators will be contactable via phone, and text message for the duration of the service opening hours (9am 5pm). 4

5 PERSON SPECIFICATION JOB TITLE: Care Navigator Knowledge Required capability Essential Desirable How assessed Healthcare industry Good knowledge of the health and social care system Skills Good command of English spoken and written A, T Time management T Strong interpersonal and communication skills A passion for exceeding customer expectations IT literate in MS Word, Excel & Outlook plus telephony systems Experience Experience of Care Planning Customer Service experience telephone and written Experience of using an appointment booking system Able to plan and organise work effectively Evidence assessed by key (A) Application form (I) Interview (T) Testing/ Assessment (P) Presentation x x I, T I, T A, T 5

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