Care Navigator - London, United Kingdom - Central London Healthcare

Description

Care Navigators play an important role within a PCN (Primary Care Network) to proactively work with patients, including the frail/elderly and those with long-term conditions, to provide coordination and navigation of care and support across health and care services. Care Navigators are based in GP practices and provide support to patients and GP staff.

This is an excellent opportunity to make a positive impact in the lives of patients and become an integral figure within General Practice.


Job Title:
Care Navigator


Salary:
£28,000 per annum


Hours:40 hours per week


Responsible to:
Senior Care Navigator


Key Relationships:
General Practice, PCNs, Central (and North West) London CCG, Healthshare

LTD, One Westminster, Central and North West London NHS Foundation Trust
(CNWL), Central London Community Healthcare NHS Trust (CLCH).


BACKGROUND
Central London Healthcare CIC (CLH) is the GP Federation covering the Central London CCG area.
The organisation supports 34 General Practices and 4 Primary Care Networks (PCNs).

We operate a number of NHS contracts including a Care Navigation Service, a Clinical Pharmacy Service, a Community Dermatology Service, and Partnership in Practice (PiP) - an out-of-hospitals provision which is sub-contracted to its 34 General Practice members.

Our vision is to be recognised as a leading GP provider network, run by clinicians for the benefit of our local population.

We will achieve this by working with patients and partners to ensure that general practice remains sustainable and independent.

Our approach is to deliver exceptional assistance to our 34 General Practice members and to operate our NHS contracts in a manner that supports our Practices and their patients by providing services economically, locally, promptly, and in a familiar environment.

Now in our 13th year we look forward to our continued growth and to contributing a voice for General
Practice in the planned Integrated Care System (ICS).


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 most vulnerable and complex patients.

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 patients.

In addition, CNs will work with the relevant agencies of the health and social care system and voluntary care services 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 Primary Care Network (PCN) made up of GP practices within Central London, and will be required to work across several practices within the designate PCN structure.

This JD is indicative and it is envisaged this job description will evolve with the CCS development.

Day-to-day work will be based in the relevant GP practices within the PCN.

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.

The CN role is instrumental within the PCN, ensuring patients care is coordinated accordingly and any preventative opportunity is taken to support the patient with taking a proactive care management approach.

ROLE SUMMARY
CN will be responsible for providing support to their nominated PCN.

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. CN will be responsible for a named list of patients within SystmOne.


Intelligent tasking. CN will refer and signpost patients to services across the community. In some 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.

"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 CNs responsibility to record the required data accurately into SystmO