This is an exciting and innovative role which will involve working alongside community GPs, paramedics, pharmacists, district nurses and a growing team of care co-ordinators and administrators to wrap care around our population as a ‘one team’ approach providing co-ordination and navigation of care and support to our patients.
Take referrals for individuals or proactively identify people who could benefit from support through care co-ordination.
Have a positive, empathetic and responsive conversation with the person and their family and carer(s) about their needs;
Work towards increasing patients’ understanding of how to manage and develop health and wellbeing through offering advice and guidance.
Develop an in-depth knowledge of the local health and care infrastructure and know how and when to enable people to access support and services that are right for them;
Work with the wider PCN, MDTs, and the social prescribing service to look at how carers can support people - this could include the initial identification of carers onto the carer register.
With training support people to develop and implement personalised care and support.
Surrey Downs Health and Care deliver care closer to people’s own communities through our Primary Care Networks, Community Hospitals, Specialist Services and our innovative partnership of local NHS organisations.
Surrey Downs Health and Care has a track record of providing person centered care that goes beyond organisational boundaries to do what is best for the individual. This partnership includes:
The three GP federations GP Health Partners, Dorking Health Care and Surrey Medical Network representing practices that operate in the Surrey Downs area
CSH Surrey
Epsom and St Helier’s University Hospitals NHS Trust
Surrey Council County
Historically, there have been boundary lines between the organisations that provide care to people in their homes, in GP surgeries and in hospitals, but we have always been united in our mission to provide great care to the people who need us.
It’s on those grounds that the Surrey Downs Health and Care was formed – we want local people to receive the care that they need in the right environment. By bringing together our expertise, we can improve patient care and enable local people to access the right support, care and treatment more easily than ever before.
In bringing this partnership together, we are working to the same set of values that will translate into better care for our residents.
Making and managing appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations.
Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through wider the health and care system.
Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns.
Keep accurate and up-to-date records of contacts, appropriately using GP and other records systems relevant to the role, adhering to information governance and data protection legislation.
Please see full description and person spec attached to this vacancy.