Integrated Neighbourhood Program LeadNHS

Job summary

Working 27 hours per week, the Marsh Neighbourhood Care Coordinator will travel across Martello, Church Lane and Orchard House Surgeries, care homes, community venues, patients' homes and partner organisations as required to support the delivery of the Single Neighbourhood Service (SNH) Direct Enhanced Service (DES), Integrated Neighbourhood Working and other proactive care initiatives across The Marsh Primary Care Neighbourhood.

Interviews will be held on Friday 9th October

Main duties of the job

The post holder will coordinate the proactive identification, assessment, review and ongoing care planning of patients within the Complex Care Patient Cohort (CCPC), including patients who are housebound, living in care homes, recently discharged from hospital and those with complex health and social care needs.

Working collaboratively with PCN practices, neighbourhood teams, community services, acute providers, social care, voluntary sector organisations and the wider multidisciplinary workforce, the post holder will act as a central point of coordination for patient pathways. They will ensure that patients progress through the agreed SNH pathway and that assessments, interventions, referrals, MDT discussions and personalised care plans are appropriately coordinated, documented and reviewed.

The role supports proactive, person-centred and holistic care, helping individuals maintain independence, improve wellbeing and access the right support at the right time.

Job description

Complex Care Cohort Coordination

• Coordinate the proactive review programme for patients identified within the SNH Complex Care Cohort.
• Maintain oversight of patients progressing through the SNH assessment and review pathway.
• Monitor cohort identification, review completion and outstanding actions.
• Maintain the SNH dashboard, patient registers and tracking systems.
• Ensure patient lists remain accurate and up to date.
• Organise clinics, appointments, home visits and review activity.
• Produce activity reports and performance updates for practices and governance meetings.

Comprehensive Assessment Coordination

The post holder will coordinate and support the collection and collation of information obtained through the SNH assessment process.

This includes coordinating information relating to:

Clinical Assessment

• Clinical reviews and outstanding clinical actions.
• Liaison with GPs, Advanced Nurse Practitioners and other clinicians.

Functional Assessment

• Mobility and balance.
• Falls history and risk.
• Activities of daily living.
• Functional independence.
• Home safety.
• Sensory impairment.

Cognitive and Psychological Assessment

• Cognitive decline.
• Dementia concerns.
• Delirium.
• Mood and emotional wellbeing.
• Ability to self-manage health conditions.

Social and Environmental Assessment

• Housing and environmental concerns.
• Social isolation and loneliness.
• Community networks and support.
• Financial concerns.
• Informal and formal care arrangements.
• Carer wellbeing and resilience.

Care Planning and Care Coordination

• Coordinate development of personalised care and support plans.
• Support creation of unified patient problem lists and patient-led goals.
• Ensure patient priorities, wishes and preferences are documented.
• Monitor and follow up agreed actions and interventions.
• Support Advance Care Planning, including ReSPECT processes, referring to clinicians where clinical decisions are required.
• Ensure care plans are reviewed and updated when circumstances change.

Discharge Support

• Attend discharge planning meetings as required.,
• Support identification of patients requiring SNH or HUMANS review following discharge from hospital.,
• Coordinate follow-up actions arising from discharge pathways.

Clinical and Medication Review Coordination

• Coordinate appointments related to clinical reviews.
• Liaise with pharmacists regarding Structured Medication Reviews.
• Monitor actions arising from medication reviews.
• Coordinate communication between patients, carers and clinicians.
• Escalate concerns regarding medication adherence, adverse effects or high-risk prescribing.

Patient Navigation and Engagement

• Act as a point of contact for patients, carers and professionals.
• Process referrals, correspondence and patient enquiries.
• Signpost patients to appropriate services and community resources.
• Promote self-management and wellbeing.
• Support patient education initiatives and engagement events.
• Ensure communication is accessible and person-centred.

Information Systems and Administration

The post holder will:

• Maintain accurate and timely patient records.,
• Record activity within EMIS and other approved systems.
• Maintain patient spreadsheets, registers and tracking tools.
• Support coding, reporting and data quality activities.
• Ensure information governance standards are maintained.
• Coordinate synchronisation of care plans to the Kent and Medway Care Record within agreed timescales.
• Support the development and maintenance o relevant Standard Operating Procedures.

Quality Improvement and Service Development

• Participate in service development and improvement initiatives.
• Participate in service development and improvement initiatives.
• Support audits, evaluations and quality improvement activities.
• Collect and review patient and staff feedback.
• Identify barriers to service delivery and escalate concerns appropriately.
• Contribute to the ongoing development of neighbourhood-based care pathways

About us

Invicta Health is a non-profit company, with a passion for primary care. We have a wide range of services such as hub-based GPs services, GP surgeries, services in Urgent Care Centres and A&E, a Community Primary Care mental health service, GP staff training service and the list is growing all the time.

We are formed by a federation of General Practitioners working in Canterbury and South Kent Coast areas of East Kent. Our aim is to provide local, high quality services for local people by collaborating with other established organisations in the health and social care community.

What perks can we offer you?

• NHS Pension
• Learning and Development opportunities
• Progression opportunities
• Competitive annual leave entitlement
• Incremental pay progression
• Flexible working
• Approved blue light card provider
• Salary Sacrifice Schemes
• Car Lease Scheme
• Employee Assistance Programme