Job Title:             HIU Care Navigator

Type:                  Fixed Term Contract until December 2025

Team:                 Care Navigation & Complex Case Management Service

Hours:              37.5 hours per week

Responsible to:             Service Manager

Salary:              £30,279.00

Key relationships:         32 General Practices, 4 PCNs, NWL ICB, Central London Borough Team, Westminster City Council, Bi-Borough (West London), Central and North West London NHS Trust (CNWL), Central London Community Healthcare NHS Trust (CLCH), One Westminster, Imperial College Health Partners

BACKGROUND

WHO WE ARE 

Healthcare Central London Ltd (HCL) is the GP Federation owned by our 32 General Practices covering the Central London (Westminster) area.  The organisation supports 4 Primary Care Networks (PCNs). We operate several NHS contracts on behalf of our PCNs including a Community Dermatology Service; Community Cardiology Service, a Secondary Care Referral Service and an out-of-hospitals provision which is sub-contracted to our 32 General Practices. 

 

On behalf of our practices we are the host employers of a large, and rapidly growing team of ARRS (Additional Roles Reimbursement scheme) roles including Clinical Pharmacists, Pharmacy Technicians, First Contact Physiotherapists, Dieticians, Paramedics, Social Prescribers, Care Coordinators, Care Navigators, Digital & Transformation Leads, Nursing Associates and GPAs. 

 

HOW WE WORK 

 

Our vision is to be recognised as a leading GP provider network, run by clinicians for the benefit of our local population and practices.  We will achieve this by working with patients and partners to ensure that general practice remains sustainable and independent. We aim to further diversify our income by exploring commercial joint ventures and expanding our research team in the coming years. 

 

Our people are our greatest asset. When we feel included, valued and supported in work this positivity reaches those very people we are here for, the patients.  HCL is committed to actively supporting diversity and inclusion and ensuring that all our employees are valued, treated with dignity and respect and enabled and supported to reach their potential. 

 

Our employees work flexibly according to the needs of our stake holders and patients, typically on site at our practices or hub sites or at our offices near Edgware Road tube station (NW1 5DH) or at our clinic at South Westminster Centre.  Our office-based roles are typically hybrid. The working patterns are agreed and reviewed according to service/team requirements. 

ROLE PURPOSE

The aim of the HIU service is to provide adequate, tailored support for people identified as High Intensity Users (HIUs) of Urgent & Emergency Care services. The intention is to improve health outcomes and reduce inequalities by identifying the most appropriate medical and psycho-social support and helping HIUs access it as needed, reducing inappropriate demand on UEC services.

The HIU Care Navigator will be responsible for coordinating and driving delivery of these services, including identifying HIUs who need additional support, reviewing their needs, referring them to suitable providers (via a local MDT as needed) and tracking those processes and outcomes.

Given the nature of the role, the individual will also be central to efforts to publicise the service to users and staff across the Borough, and working with a wide range of health, social care and third sector organisations to prioritise care for this highly vulnerable group. This will include facilitating discussions between primary care, hospital and community services. The post holder will be required to manage patient caseloads and advise on improvements, which will be used to deliver measurable outcomes for the benefit of patients, staff and the public.

The role requires extensive liaison with statutory and non-statutory services, to review and support the flow of referrals into the service and involves:

·       Identifying an agreed number of HIUs attending Emergency Department each month

·       Reviewing their needs (with suitable clinical and other support)

·       Identifying which services are best placed to provide that support

·       Referring patients and making sure their care is picked up

·       Where necessary, referring people to the appropriate local MDT meeting for a wider review if needed, before onward referral

·       Tracking the processes and outcomes of the service

·       Providing information and training to local health and social care professionals

Once training has been completed, the role is hybrid: 4 days in Practice and 1 day working remote.

KEY TASKS AND RESPONSIBILITES

·       The role is predominantly non patient facing and support will be provided via telephone.

·       Responsible for tracking patient activity through use of the HIU dashboard and maintaining accurate records on the Patient Activity Tracker.

·       Responsible for organising and coordinating attendance at MDT meetings, recording accurate minutes and working with local providers to prioritise the needs of this highly vulnerable group.

·       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, completing Care Plans and delivering targeted public health messages to patients.

·       Ensure coordinated and effective delivery of the patient’s Care Plan for those patients identified through risk stratification by the GP.

·       Work collaboratively with colleagues across health, social care and the third sector to provide patient-centred care.

·       Contribute towards other administrative tasks within the GP Federation.

·       Lead on the creation of patient Care Plans and support patients throughout their interactions with primary care services.

·       Assigned to specific GP Practices within the GP Federation and will be required to work across several practices within the designated PCN structure.

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

 

MAIN DUTIES ON THE JOB

Clinical Systems/Medical Records

·       Use SystmOne to record all patient interactions, using appropriate templates and in accordance with GDPR regulations.

·       Maintain up to date and accurate records.

·       Effective and timely response to ‘tasks’ sent assigned to the CN.

·       Support patients via Surgery Connect telephony system and email.

·       Maintain up to date records both internally and externally.

General Duties & Responsibilities

·       Support patients to develop and review Care Plans in line with a personalised care approach, to manage their needs and achieve better healthcare outcomes.

·       Chair and participate in regular MDTs and ICTs as required

·       Provide coordination and navigation for people and their carers across health and care services. Helping to ensure patients receive a joined-up service and the appropriate support from the right person at the right time.

·       Refer onwards to other health and social care providers where required where there is an unaddressed need

·       Proactively identify when action or additional support is needed, alerting relevant professionals, and highlighting any safety concerns.

·       Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role. Ensuring work is delivered in a timely and effective manner.

·       Work collaboratively with the Care Navigator team to meet organisation and personal targets especially with Specialities ie. Dementia/Housing/Homeless/Asylum which also will be Face to Face.

·       Support and lead on delivery of HIU service

Equality and Diversity

The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:

·       Acting in a way that recognizes the importance of people’s rights, interpreting them in a way that is consistent with Practice & PCN procedures and policies, and current legislation.

·       Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.

·       Behaving in a manner which is welcoming to and of the individual, is non-judgmental and respects their circumstances, feelings priorities and rights.

The above list of job duties is not exclusive or exhaustive and the post holder will be required to undertake such tasks as may reasonably be expected within the scope of the post. 

Requirements

PERSON SPECIFICATION

ATTRIBUTE / SKILLS

MEASUREMENT

Application form / CV 

Original certificates / diplomas

ESSENTIAL

English and Maths GCSE.

Specialist knowledge / interest acquired through training and extended courses related to healthcare

DESIRABLE

Can demonstrate knowledge of health inequalities and health disparities. Understanding of health and social care processes and current issues facing the NHS

Knowledge of homelessness, substance misuse and mental health.

An understanding of the local borough population.

Knowledge on how to access social support in the client’s local area and how to access support. 

SKILLS / 

ABILITIES 

MEASUREMENT

Application form / CV

Interview

Assessments

ESSENTIAL

Proven record of excellent written and verbal communication and interpersonal skills.

Good organisational and time management skills.  

Able to prioritise and manage own workload and show initiative to complete tasks independently and with multi-disciplinary teams

Excellent motivational and influencing skills.

Proficient in Microsoft applications and familiar with IT systems.

Strong analytical and judgement skills. Able to interpret information and present results in a clear and concise manner.

High level of self-motivation, drive for performance and improvement, and flexibility in approach

DESIRABLE

A commitment to improving patient care.

Experience providing advice/signposting to staff.

Long-term conditions training

Welfare Rights basic training 

Vulnerable adult’s awareness

EXPERIENCE 

MEASUREMENT

Application form

Interview

References 

ESSENTIAL

Experience of administrative duties.

Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality. 

Worked in a multi-disciplinary setting where influence and negotiation is required.

Knowledge/familiarity with medical terminology.

Worked in a busy and demanding environment whilst delivering in a timely manner. 

DESIRABLE

Previous experience of working in a clinical healthcare setting.

Experience of working with patients with mental health and/or addictions. 

Experience in use of databases.

COMMUNICATION SKILLS 

MEASUREMENT

Application form

Interview

Assessments

DESIRABLE

Ability to establish credibility and develop and maintain effective working relationships with both clients and the wider team.

Excellent inter-personal, communication, negotiation and influencing skills.

Strong sense of commitment to openness, honesty and integrity in undertaking the role.

APTITUDE/ PERSONAL QUALITIES 

MEASUREMENT

Application form

Interview

Assessments 

ESSENTIAL

Professional attitude and assertive approach.

Conscientious, hardworking and self- motivated to work with minimal supervision.

Able to meet deadlines and work under pressure.

Creative and tenacious in finding solutions to difficult problems.

Demonstrate ability to work with information, clinicians, social workers and managers. 

DESIRABLE

Willingness to undergo further training or development. 

Requires a flexible approach, and a highly motivated post holder.  

PHYSICAL QUALITIES

MEASUREMENT

Application form

Interview 

Assessments 

ESSENTIAL

Sufficient to fulfil the duties of the post with any aids and adaptations. 

VALUES

MEASUREMENT

Interview 

ESSENTIAL

Demonstrable ability to meet the organisation’s values.

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.