Greenwich Long Term Conditions (LTC) Care Coordinator

Job summary

***Important Sponsorship Information for this post: We are currently unable to offer a certificate of sponsorship for this post***

We are looking to recruit 4 x LTC Care Coordinators who will each manage a defined caseload of residents with multiple long-term conditions and complex health and social care needs. Acting as the named coordinator and principal point of contact for residents, families and carers, the post holder will support individuals to progress the agreed actions within their care plan. They will identify risks, barriers and unmet needs, coordinate appropriate interventions, monitor progress, and take timely action where deterioration or increased risk is identified.

Main duties of the job

The LTC Care Coordinator will play a key role in coordinating care, including arranging appointments and ensuring patients are discussed at integrated case management (ICM) meetings and multidisciplinary team (MDT) forums where appropriate, particularly for complex cases. They will support delivery of agreed actions following holistic assessments, ICM meetings and MDT discussions. The role aims to deliver proactive, holistic and person-centred care that improves outcomes, strengthens self-management and reduces reliance on unplanned care. The post holder will prepare cases for ICM and MDT meetings, coordinate implementation of agreed MDT actions, and escalate complex cases through appropriate governance arrangements.

About us

Oxleas offers a wide range of NHS healthcare services to people in community and secure environment settings. Our services include community health care such as district nursing and speech and language therapy, care for people with learning disabilities and mental health care such as psychiatry, nursing and therapies. Our multidisciplinary teams look after people of all ages and we work in close partnership with other parts of the NHS, local councils and the voluntary sector and through our new provider collaboratives. Our 4,300 members of staff work in many different settings including hospitals, clinics, prisons, secure hospitals, children's centres, schools and people's homes.We have over 125 sites in a variety of locations in the South of England. In London we operate within the Boroughs of Bexley, Bromley Greenwich and into Kent. We manage hospital sites including Queen Mary's Hospital, Sidcup and Memorial Hospital, Woolwich, as well as the Bracton Centre, our medium secure unit for people with mental health needs. We are the largest NHS provider of prison health services providing healthcare to prisons within Devon, Dorset, Bristol, Wiltshire and Gloucestershire, Kent and South London. We are proud of the care we provide and our people.

Our purpose is to improve lives by providing the best possible care to our patients and their families. This is strengthened by our new values:

• We're Kind
• We're Fair
• We Listen
• We Care

Job responsibilities

• Care Coordination and Case Management
• Independently manage a defined caseload and prioritise residents according to risk and complexity with multiple long-term conditions and complex health, wellbeing and social care needs.
• Act as the named care coordinator and key point of contact for residents, carers and families.
• Undertake case management to action needs identified e.g. physical health, mental health, social, housing and wellbeing needs.
• Work with residents to identify priorities, agree goals and develop personalised care and support plans.
• Coordinate interventions across multiple services and organisations to ensure care is delivered in a timely and coordinated manner.
• Monitor progress against agreed care plans and take appropriate action where risks, deterioration or barriers to engagement are identified.
• Support residents to access services, appointments and community resources, reducing barriers to care and improving health outcomes.
• Encourage and support residents to develop confidence in self-management and shared decision making.
• Facilitate referrals and access to appropriate services without unnecessary duplication or delays.
• Act as the named LTC Care Coordinator for a defined caseload of adults living with long-term conditions and other complex health and social care needs, building ongoing, trusted relationships with each individual.

Person specification

Education and Qualifications

Essential

• Level 3 Diploma in Adult Care (RQF) or equivalent experience/ GCSE or equivalent in English and Maths, Grades A - C or 9-4/ Continuing CPD

Experience

Essential

• Experience working within health, social care, community or voluntary sector services, across multiple organisations, participating in multidisciplinary or multi agency meetings, managing sensitive/confidential information/ handling difficult situations, knowledge of community healthcare and social care

Skills

Essential

• MS Office and electronic record systems
• Prepare reports, analyse information, organisational skills, problem solving, communication skills