Communication and Working Relationships

On a daily basis communicate with colleagues from the Health and Social care team and ensure that relevant information is shared between professionals to aid management of complex clients in the community. 

Contact clients on the phone to gather or impart basic information; this may include people with varying degrees of communication difficulty for example dysphasia, sensory impairment or mental health issues. Ensure empathy, negotiation, tact in these situations and also ensure the ability to manage clients who may be low in mood, lacking in motivation, or angry/upset about their current circumstances.

To liaise, work closely and form strong links with all members of the Multidisciplinary team and work closely with outside agencies on a regular basis. For example, communicate the need to regularly communicate with occupational therapists, physiotherapists, district nurses, GPs, staff in acute hospital setting, community mental health nurses, social care workers and private providers of care.

On a daily basis communicate medical and social information to the above via various sources including telephone, email or face to face correspondence. This information is always confidential, frequently sensitive and can be contentious and as a result needs to be provided in a professional, appropriate and polite manner in line with data protection and information governance policy.

To contribute to multi-disciplinary team meetings in relation to current caseloads and implementation of actions required for example organising of home assessment visits, discharges, transport bookings and requesting packages of care.

Planning and Organisation

To be able to work in a demanding, pressured and stressful environment with constant interruptions by telephone, colleagues and professional office visitors, all relating to current cases or new enquiries. 

To be able to multi-task, re-prioritise your workload at short notice and identify risks and urgent work that requires action. 

Demonstrate the ability to undertake duties in an autonomous manner. 

 Coordination for Community teams: primarily intermediate care, also to include as required: nursing, therapies + social care and occasionally related out of hours support.

 Co-ordination of the regular multi-disciplinary meetings, and other relevant meetings designed to aid management of complex clients living in the community. 

With assistance from professional colleagues, screen and triage referrals to health and social care and obtain further info where required so a decision can be made about the best pathway for new referrals.

Awareness and involvement in primary care core group discussions designed to support those clients who are the most vulnerable people living in the community. This may include generating lists of clients to be discussed and gathering information updates from any relevant professionals.

Awareness of urgent care response pathways, supporting with relevant referrals across services.

Follow up outstanding activities with non-attending team members and feedback on cases where appropriate.

As a member of the multi-disciplinary team continue developing and expanding on the good working relationships that exist between all services.

To coordinate short term intermediate care placements (following the local procedure) including the completion of relevant paperwork and entering of this information onto relevant systems and spreadsheets.

To participate in local service development activities and help implement change as and when required

To support with co-ordinating referral pathways for the wider teams: social care, therapies and nursing as required. 

Customer Service (Social care)

 To provide a client centred approach to ensure all clients and carer’s views and opinions are considered and all people who are who are given an enquiry are given respect, dignity and understanding. Delivering a high quality, efficient and effective service at all times complying with equality and diversity policies and legislation.

The recording of contacts in a consistent manner by completion of a contact assessment where appropriate, or an ‘observation’ record on Care first 6. This may involve face to face contact at the office and taking contacts from other agencies. 

Identify urgent assessments that need action, alert and liaise with local ACS practice managers / community nurse team manager or therapy manager. 

The effective signposting of contacts to other agencies or sources of help as appropriate.

To provide feedback to referrers about the outcomes of contacts and assessments in accordance with the agreed quality standards. 

To ensure confidentiality process is followed at all times.  

Information Technology and Administrative Duties

The post holder must have excellent keyboard skills and ability to use multiple IT systems on a daily basis to obtain & record information- systems used include Systmone, Carefirst 6, Clinical Portal, Nervecentre, DATIX & IHCS.  

To have good ability to use spreadsheets and word processing packages, e.g. to maintain staff training & lone working details. 

To have the ability to send and receive emails.

To ensure the information governance requirements for recording community health and social care activity are adhered to in collaboration with other team members.

Accurate inputting onto relevant IT systems to ensure any statistical data is up to date and accurate.