Integrated Neighbourhood Team (Int) Caseworker

North Lewisham Primary Care Network; Lewisham; Sur place; GBP 28 000 - 36 000; Plein temps

Résumé du poste

North Lewisham PCN is seeking an INT Caseworker to support the implementation of Lewisham NHS 10-Year Plan through integrated neighbourhood teams. The role focuses on prioritising complex caseloads, conducting holistic assessments, and coordinating steps that ensure appropriate signposting and service access for residents with multiple cardiovascular LTCs.

The successful candidate will work with health, social care and community services to streamline care pathways and improve residents’

Responsabilités

• ,Analyse and assess population health data to identify high-priority patients or cohorts for INT intervention using EMIS Web, Excel, AccuRx and Ardens;
• Manage and maintain the INT caseload, ensuring efficient prioritisation and monitoring of patient progress.
• Collaborate with multidisciplinary teams (MDTs) to coordinate and manage patient support plans.

Connaissances

Population health analysis

Care coordination

Collaboration with MDTs

Outils

EMIS Web

Microsoft Excel

AccuRx

Ardens manager

Description du poste

Job summary

Following the recent NHS 10year plan, Lewisham is transforming care by establishing Integrated Neighbourhood Teams (INT). The INTs are designed to deliver coordinated, community-based care and support.

To ensure a controlled and effective rollout, the initial focus of INTs will be on supporting patients with three or more cardiovascular long-term conditions (LTCs) including diabetes, atrial fibrillation, chronic kidney disease and hypertension.

Residents accessing the service will receive holistic support that addresses both physical and social factors affecting their lives. This includes:

• Analyse and assess population health data to identify high-priority patients or cohorts for INT intervention using e.g. EMIS Web, Microsoft Excel, AccuRx, Ardens manager and other systems as needed.
• Manage and maintain the INT caseload, ensuring efficient prioritisation and monitoring of patient progress.
• Collaborate with multidisciplinary teams (MDTs) to coordinate and manage patient support plans.

We are looking for an individual with a passion for providing proactive, person-centred care to work as an INT Caseworker within the Lewisham Community for the North Lewisham PCN.

Main duties of the job

The INT Caseworker will play a central role in supporting the implementation and delivery of Lewisham NHS 10 -Year Plan for integrated neighbourhood working.

The role holder will focus on improving outcomes for residents by streamlining care pathways, managing complex caseloads, conducting holistic assessments, and ensuring individuals receive the right support through effective signposting and coordination.

Acting as the critical link between health, social care, and community services, the INT Case