Care Home Care Planning Practitioner

An opportunity has arisen to join the Urgent Care & Support Service at Your Healthcare as a Care Home Care Planning Practitioner, working to reduce hospital admissions from Nursing, Residential and Learning Disability care homes, enhancing MDT working and the use of Universal Care Plans. The team responds to urgent care visits providing advanced clinical assessment, diagnosis and management which includes proactive support and clinical education in combination with a dedication to building a network of health and social care professionals working together.

The postholder will support the delivery of enhanced MDT working in care homes across Kingston and work in partnership with care homes, Care Home (GP) Leads, acute and community services to deliver enhanced MDT working and increase the use of the Universal Care Plans.

The postholder will collaborate with professionals to initiate care planning discussions including advance care planning, comprehensive geriatric assessment, frailty, and dementia to initiate and complete a universal care plan.

This enhanced approach to MDT working and care planning aims to improve the use of the health and care system by intervening earlier, proactively, and more holistically for residents of care homes.,

• The proof of concept to deliver MDTs in Care Homes has been modelled in line with the Proactive Anticipatory Care (PAC) Programme which ran as a successful proof of concept for two years, followed by a borough-wide roll out in September 2023.


• The post will be fundamental in supporting the Care Home MDT meetings to function effectively, implement changes to ways of working and evaluate the success of the model.


• Support GPs with their ward rounds, proactively identifying residents who need attention and support care home staff to update Universal Care Plans as appropriate.


• Participate in MDT meetings to help residents to navigate community and specialist services.


• To participate in working with care home staff to identify and manage residents with complex or long-term conditions, prevent admission to hospital and advising on nursing intervention to avoid deterioration
  
  It is essential that candidates have both experience of and interest in MDT working and Advanced care planning. You will have excellent written and verbal communication skills and good attention to detail. You will be competent and confident in the use of IT systems/platforms used within Your Healthcare. You will welcome the opportunity to take on new challenges and thrive in a busy and demanding environment. You will have the ability and confidence to problem solve and self-learn and enjoy working independently as well as part of a team.
  
  Welcome to Your Healthcare CIC. We are a not-for-profit social enterprise, proud of delivering patient-led, high-quality health and social care community services for residents in Kingston & Richmond as part of the NHS family.