Proactive Care Practitioner

The Proactive Care Practitioner will provide a responsive, safe, effective caring Proactive Care service. The service aims to support an identified cohorts of people living with mild to moderate frailty and long term conditions, providing comprehensive assessment and proactive case management.

This will include adopting a shared decision making approach and supporting self-management through sign-posting, health coaching and social prescribing, MDT discussion and onward referral as required.

The Proactive Care service, whilst operating from a local hub, will require travel to Practices or patients homes across the Surrey Heath PCN geography.

Main duties of the job

To work closely with the Integrated Care Team, Frailty MDT and local GP teams to provide proactive care services for patients with frailty or those with a long term condition identified as requiring an anticipatory approach.

To support the identification of the target cohort for whom there is the greatest potential impact on health and system outcomes.

To provide specialist assessment of patients, using analytical and judgment skills. To provide appropriate patient centred treatment using evidence based practice where-ever possible. Patients will present with acute or chronic conditions and complex multi-system pathologies e.g. neuro, respiratory conditions, orthopaedic rehabilitation and age related deterioration.

To ensure holistic assessment using an agreed approach, such as comprehensive geriatric assessment (CGA).

To devise effective personalised care plans for each patient with specific therapeutic knowledge, recognising him or her as an individual. The plan of care, which has been developed in conjunction with the patient, carer and relevant others, should be outcome based and ensure appropriate pathways of care and communication via liaison and referral to other agencies as required.

We are Surrey Heath Community Providers Limited, which is a federation of 7 GP practices across 10 sites, covering a population of over 103,000 patients across Surrey Heath. We began in 2016 and now employ around 200 members of staff across our head office sites, and our primary care and unplanned care services.

As a GP Federation, we are proud to represent our member practices and to champion primary care by working with local general practice and system partners in the provision of community-based healthcare services. We are dedicated to providing safe and compassionate care to our patients across our range of primary care and unplanned healthcare services in Surrey Heath, and believe in continuous commitment to quality service delivery and positive patient outcomes.

Patients are at the heart of everything we do, and we pride ourselves in ensuring our patients feel safe, supported, communicated with and respected, at a time when they may be feeling vulnerable. Our vision is to provide high quality, seamless health care that enables people to lead healthier lives, whilst feeling supported and cared for.