HIU Care Navigator

at  Healthcare Central London

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.

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.

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