We are looking for an experienced registered senior practitioner (you could be a community nurse, occupational therapist, or paramedic), with a strong sense of social justice, to join the Homeless Health Inclusion Team to expand the model of care delivery to people involved in the Single Homeless Application Program (SHAP). We deliver transformational models of physical and mental healthcare to people experiencing homelessness, Gypsy and Traveller communities, and inclusion health groups across Leeds in partnership with the third sector, Leeds City Council, Primary Care, Adult Social Care and Leeds Teaching Hospital Trust. We manage a caseload of people into our specialist intermediate care model post discharge from hospital or coordinate and case manage to avoid unnecessary admissions. We provide

• Health services in intermediate care beds.
• Specialist GP, nursing and navigator assessment to hospital patients identified as experiencing homelessness.
• Case management, working with housing and other services to ensure accommodation and support is accessed. We signpost to community services to avoid readmissions to hospital. Actively working with individuals in intermediate care beds to ensure a maximum length of stay as clinically appropriate and liaise with other agencies to source appropriate accommodation for them to move in to.
• Detailed needs assessment to aid continuity of care.
• Additional flats as part of the out of hospital service.
Main duties of the job The SHAP programme is targeted at those with the longest histories of rough sleeping or the most complex needs and vulnerable young people (age 18-25) at risk of homelessness or rough sleeping. You will work with those with the longest histories of rough sleeping, working collaboratively and assessing their health needs and supporting their health goals. You will represent health at strategic meetings whilst also having a clinical caseload. You will
• work to expand the current offer of Intermediate Care.
• visit patients in temporary accommodation, and patients homes to assess health needs and facilitate a secondary or community care offer.
• develop links with other services.
• holistically assess health needs and work with patients on self-identified health goals.
• coordinate complex safe discharge from hospital.
• identify and implement appropriate interventions.
• provide education to stakeholders.
• facilitate primary and community care offers for wound care, medication reviews, and ongoing monitoring of long-term condition management.
• be involved in multi-agency working.
• attend city meetings, influencing strategy for our patient group.
• lead MDT meetings.
• collect data & conduct clinical audits.
• deputise for the Homeless Integration Lead.
  
  Working for Leeds community Healthcare NHS Trust, Leeds Community Healthcare provides a range of community-based health services across the whole city. We treat people in their homes, local health centres and community hospitals, and work in partnership with other local Trusts, charities and Leeds City Council.
We have a strong culture based on deeply-held values, and our focus at all times is on delivering high quality care to the people of Leeds. In our most recent CQC evaluation, we were rated "Good", with our Adult Services rated "Outstanding" for caring.