Proactive Care Lead, High Intensity Service Users

NHS Jobs; Coventry; On-site; GBP 60,000 - 75,000; Full time

Job summary

NHS Jobs in Coventry is seeking a Proactive Care Lead for High Intensity Service Users to coordinate holistic assessments and personalised care planning. The role involves working with multidisciplinary teams to identify risk, implement care plans, and reduce avoidable hospital attendances.

You will promote self-management, address health inequalities, and ensure patients access the most appropriate community and primary care pathways. Excellent collaboration and advocacy are essential.

Responsibilities

• Proactively identify and support high intensity service users who frequently access acute, community, primary care, urgent and emergency care services, ensuring their needs are assessed holistically and managed through coordinated care planning.
• Undertake comprehensive assessments of individuals with complex health, social, psychological, and behavioural needs to understand the factors contributing to high service utilisation and identify opportunities for alternative approaches to care.
• Develop, implement, and regularly review personalised care and support plans that promote self-management, improve health outcomes, and reduce avoidable healthcare attendance and admissions.
• Work collaboratively with multidisciplinary teams, including acute, community, primary care, mental health, social care, and voluntary sector services, to coordinate appropriate interventions and ensure seamless care delivery.
• Act as a key point of contact for high intensity service users, providing case management, advocacy, and support to navigate services and access the most appropriate care pathways.
• Identify patients who may benefit from receiving care in alternative settings, such as community services, primary care, outpatient clinics, or other specialist support services, ensuring care is delivered in the most appropriate and least restrictive environment.
• Monitor patterns of service utilisation and identify trends, risks, and opportunities for intervention to improve patient outcomes and reduce unnecessary demand on healthcare services.
• Support the development and implementation of strategies, pathways, and initiatives aimed at improving care for high intensity service users, reducing health inequalities, and promoting integrated care across organisational boundaries.
• Maintain accurate records, collect relevant data, and contribute to service evaluation, quality improvement, and reporting requirements to demonstrate outcomes and inform future service development.
• Build effective relationships with patients, carers, families, and partner organisations to promote person-centred, coordinated care that improves patient experience and quality of life.

Job description

Proactive Care Lead, High Intensity Service Users

Proactively identify and support high intensity service users who frequently access acute, community, primary care, urgent and emergency care services, ensuring their needs are assessed holistically and managed through coordinated care planning. Undertake comprehensive assessments of individuals with complex health, social, psychological, and behavioural needs to understand the factors contributing to high service utilisation and identify opportunities for alternative approaches to care. Develop, implement, and regularly review personalised care and support plans that promote self-management, improve health outcomes, and reduce avoidable healthcare attendance and admissions. Work collaboratively with multidisciplinary teams, including acute, community, primary care, mental health, social care, and voluntary sector services, to coordinate appropriate interventions and ensure seamless care delivery. Act as a key point of contact for high intensity service users, providing case management, advocacy, and support to navigate services and access the most appropriate care pathways. Identify patients who may benefit from receiving care in alternative settings, such as community services, primary care, outpatient clinics, or other specialist support services, ensuring care is delivered in the most appropriate and least restrictive environment. Monitor patterns of service utilisation and identify trends, risks, and opportunities for intervention to improve patient outcomes and reduce unnecessary demand on healthcare services. Support the development and implementation of strategies, pathways, and initiatives aimed at improving care for high intensity service users, reducing health inequalities, and promoting integrated care across organisational boundaries. Maintain accurate records, collect relevant data, and contribute to service evaluation, quality improvement, and reporting requirements to demonstrate outcomes and inform future service development. Build effective relationships with patients, carers, families, and partner organisations to promote person-centred, coordinated care that improves patient experience and quality of life. For further details of the role please see the attached job description.