Care Planning Practitioner

The Care Home Support Team in Richmond have an exciting new opportunity for you to join our dynamic team as a care planning practitioner.
Working in partnership, the postholder will support the ongoing implementation of integrated neighbourhood teams and MDT working in care homes across the Borough of Richmond.
You will support the implementation, management and delivery of enhanced MDT working in care homes across Richmond. The postholder will 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 Plan.
You 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 postholder will support primary and community care to effectively deliver, implement and evaluate changes to ways of working.
The service operates 5 days a week, Mon - Fri 8am - 4pm, Work in collaboration with Health Care Professionals supporting care home residents and to identify those at risk of deterioration, deconditioning or admission for discussion with the MDT, initiate or review of advance care plans through the UCP.
Monitor hospital admissions A&E attendance & ambulance call rates for care homes in the Richmond borough liaising with Kingston Hospital Foundation Trust Transfer of Care Hub, Discharge Coordinators and other key personnel to enable proactive working and provision of targeted support to facilitate earlier discharge and prevent unnecessary admission to hospital for care home residents.
Support care homes, linked G.Ps and Adult Services to work collaboratively to achieve effective communication and provision of proactive medical/nursing/therapeutic care to facilitate earlier discharge and prevent unnecessary hospital admissions
Collect data as required supporting audit focusing on health outcomes and reduction of acute hospital emergency bed days.

Community healthcare is unlike any other part of the NHS. It's personalised care that helps people to retain their independence. It's the NHS at its best and the difference you make is truly tangible. Our colleagues often describe us as a family, and we know how important that sense of belonging and support is when you start a new job. It's simple - happy, engaged staff provide better services.
In 2018, we were named 'Best Place to Work for Employee Satisfaction' by the Nursing Times. The same year, we won the Workforce category at the HSJ Awards. In the latest NHS Staff Survey results 2020, we had the best response rate amongst community trusts nationally.
We are the top community trust in the country on the theme Quality of care for the third year. We had the highest percentage of staff who felt they are able to deliver the care they aspire to and are satisfied with the quality of care they give to patients or service users.
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