Armed Forces OpCOMMUNITY Personalised Care Coordinator

at  Alliance for Better Care CIC

Primary duties and areas of responsibility Hold a caseload of up to 50-100 people per year. Help improve care and support for Armed Forces families and carers, by acting as an advocate and navigator through the healthcare system. Implement a social prescribing approach (where appropriate) to help empower individuals take control of their health and wellbeing and support their independence. This caseload will vary based on post holders capacity.
To work with NHS Trusts particularly Armed Forces Leads to identify and support individuals to access services whether specialised services, remove disadvantage and implementing special provision in line with Armed Forces Act. Working with GPs/primary care across the system to ensure individuals are referred into the appropriate services and in line with the Act. Ensuring shared learning and support to Link Workers and OpCommunities across England, Sussex and Kent and Medway. Promote the service while maintaining a focus on equity, and being proactive in developing strong links with local agencies.
Care Coordination and Integration To provide a central point of contact for Armed Forces community (Serving, Reservists, Veterans, and their families including transferring and resident families and carers within the Armed Forces community) offering advice and signposting to ensure a streamlined service for the patient. To undertake an initial triage by monitoring the AFN website, email and telephone. To work with a range of multi-disciplinary professionals who are involved in a service users care, to ensure a streamlined and coordinated approach, especially where multiple agencies are involved. Assist and empower the individual to consult and collaborate with other health care providers and specialists to set up appointments and treatment plans.
To identify where there is a need for urgent action or for an escalation in care and alert the relevant professional(s). Providing the practical link between the individual, health care professional, social care, third sector and other resources, to enable a good quality outcome for the management of care and for a satisfactory patient/carer experienceManaging Social Prescribing Caseload Speak to people on a one-to-one basis giving service users time to tell their stories and focus on what matters to them. Build trust with the person, providing non-judgemental support, respecting diversity, and lifestyle choices. Work from a strength-based approached focusing on a persons assets.
Provide ongoing support for an individual and promote engagement with identified services and achievement of goals. Be a friendly source of information about well-being and prevention approaches. Help people maintain or regain independence through living skills, adaptations, enablement approaches and simple safeguards. Work with individuals to co-produce a simple personalised support plan based on the persons priorities, interests, values and motivations including what they can expect from the groups, activities and services they are being connected to and what the person can do for themselves to improve their health and wellbeing.
Where appropriate, physically introduce people to community groups, activities, and statutory services, ensuring they are comfortable. Record Keeping To keep accurate and up-to-date records, including the use of GP databases such as EMIS. To utilise the SOLLIS risk stratification tool in identifying patients and tracking how interventions are affecting their risk of hospital admission. Ensure the directories are updated as required.
The Forces Connect App will be updated with any changes as required and during review. Use accurate SNOMED codes to record service user contacts and interventions, mainly via the use of provided templates, for audit purposes and monitoring and measuring outcomes. Manage reporting required for services. General Responsibilities Work as part of the team to seek feedback, continually improve the service and contribute to future planning.
Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner. Treat individuals with empathy and respect and conduct oneself in a professional manner. Attend meetings as appropriate and supporting any necessary project reporting. Build relationships with key staff across the system attending relevant meetings becoming part of the wider network team, giving information and feedback.
Be proactive in developing strong links with all local agencies to encourage referrals. Highlight any safeguarding concerns as a priority to your line manager. Other Key Tasks Contribute to the development of the service and participate in support, supervision and training as required. Maintain standards and practice in relation to professional records/ record keeping.
Highlight any safeguarding concerns as a priority to your line manager Adhere to all professional and clinical policies within ABC. Be prepared to work flexibly and to travel across Sussex/Kent/Medway on an ad-hoc basis

Please refer the Job description for details