Home First Virtual Ward Patient Co-ordinator - Surrey Downs H&C

Surrey Downs Health & Care
An opportunity has arisen to join our Home First team in the newly developed role as a Patient Co-ordinator. If you can work autonomously, have good communication skills and care about helping to keep people out of hospital this could be the role for you.
This is an exciting and innovative role which will involve working alongside the Home First Virtual Ward multidisciplinary team. The team works 8am-8pm 7 days a week and includes doctors, advance clinical practitioners, therapists, paramedics, pharmacist and nurses.
Virtual Ward is a new type of hospital-level care provision that has been set-up which sees patients remain at home with the support of a multidisciplinary team. Patients can step-up from a community assessment with community health services or step-down from acute assessment and care in A+E or hospital wards to ensure their recovery at home or in a care home from short term illness, generally staying on the Virtual Ward for around a week.
Work with the Virtual Ward MDT to manage a caseload of patients, acting as a central point of contact to ensure appropriate support is made available to them and their carers; co-ordinating the patient journey during their VW admission; achieved by co-ordinating referrals to VW and all the information about a person’s identified care and ensuring patients are scheduled for clinical assessment. Patients who receive digital monitoring are on-boarded by the patient co-ordinator with provision of equipment, demonstration of usage and set-up on the remote digital monitor dashboard. This role will facilitate discussion of these patients at the daily VW round with earlier escalation of clinical discussion if warranted by digital remote monitoring results falling outside desired set parameters. The patient co-ordinator will be responsible for organising the collection of equipment loaned to patients while on the VW. This role is intended to be an integral part of the Home First MDT, working alongside other aspects of the service to provide person centred co-ordination of the patient journey through Home First while on Virtual Ward, including communication with other services. The role is not clinical but it is expected that the post holder will visit people face-to-face in a variety of settings. The post holder will need to be able to manage and support patients and carers with remote digital technology and escalate results that fall outside of set parameters.
Surrey Downs Health and Care deliver care closer to people’s own communities through our Primary Care Networks, Community Hospitals, Specialist Services and our innovative partnership of local NHS organisations.
Surrey Downs Health and Care has a track record of providing person centered care that goes beyond organisational boundaries to do what is best for the individual. This partnership includes:

• The three GP federations GP Health Partners, Dorking Health Care and Surrey Medical Network representing practices that operate in the Surrey Downs area
• CSH Surrey
• Epsom and St Helier’s University Hospitals NHS Trust
• Surrey Council County

Historically, there have been boundary lines between the organisations that provide care to people in their homes, in GP surgeries and in hospitals, but we have always been united in our mission to provide great care to the people who need us.
It’s on those grounds that the Surrey Downs Health and Care was formed – we want local people to receive the care that they need in the right environment. By bringing together our expertise, we can improve patient care and enable local people to access the right support, care and treatment more easily than ever before.
In bringing this partnership together, we are working to the same set of values that will translate into better care for our residents.
Some of the responsibilities are highlighted below, please review Job description for full list

• Work with people, their families and carers to improve their understanding of the patients’ condition and support them to develop and review personalised care and support plans to manage their needs and achieve better healthcare
• Help people to manage their needs through answering queries, scheduling appointments, and ensuring that people have good quality written or verbal information to help them make choices about their
• Provide co-ordination and navigation for people and their carers across health and care services, working closely with Home First team members and other primary care professionals; helping to ensure patients receive a joined-up service and the most appropriate
• Work collaboratively with GPs and other primary care or community health care professionals and the Virtual Ward MDT to proactively identify and manage the Virtual Ward caseload. This may include patients with long-term health conditions, including frailty, dementia and End of Life Care needs.
• Work with people, their families, carers and healthcare team members to encourage effective help-seeking
• Support the Virtual Ward developing communication channels between GPs, community services, Community Matrons, people and their families and carers and other
• Utilise communications from hospital and in-patient services, General Practice and community services to inform the patient care pathway.
• Maintain records of referrals and interventions to enable monitoring and evaluation of the service.
• Contribute to risk and impact assessments, monitoring and evaluations of the service