Care Planning Practitioner

Job overview

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

Main duties of the job

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.

Detailed job description and main responsibilities

**Please see the attached supporting job description and person specification document, which contains more information about the role and requirements. Please ensure your application refers to the job description and person specification**