Personal Independence Coordinators across South West London

The service will provide care coordination and / or case management for frail and vulnerable individuals who are eligible for the service. This includes: • Provision of a service Monday to Friday, 09:00 - 17:00pm or as appropriate. • Attending GP Huddles weekly or fortnightly as agreed with GP practices. • Undertaking a holistic, person-centred assessment and guided conversation in partnership with the individual, supporting the individual to consider and set their own goals with encouragement to recognise what is important to them • Working collaboratively with GP Practices, Hospital, Community Health, Social Care, Mental Health, Hospice and Voluntary sector partners in an integrated, whole system approach to support holistic care management including how to support "Making Every Contact Count" • Liaising with GP Huddle Network Facilitators, GPs and other ICN core team members to proactively identify individuals who might benefit from being discussed at GP Huddles. This will include proactively using available risk stratification tools to support the identification of vulnerable people who might benefit from support from the service • Provide case management support, depending on need. This should address: • Access to other services which could include providing hospital and other health and care appointment coordination support as required through telephone reminder or arranging for the individual to be physically accompanied to hospital especially for people with dementia, • Proactively managing communication with the Patient's GP and other relevant ICN core team members to include discharge letters or PIC Summary) to the individual's GP practice within the target time indicated in the service key performance indicators following discharge • Be a general care coordinator to ensure health and care are linked up and not duplicating to ensure wrap-around support for the person • Exploring ways to continue appointment coordination once PIC intervention has concluded • Case managing individuals for up to 6 or 12 weeks, depending on the level of need of the client. • Provide timely and focused support enabling Clients to achieve goals which focus on maintaining and developing daily living skills and build the confidence to carry them out independently, or with a minimum level of support. • Promoting health and wellbeing and self-care / self-management approaches to enable greater independence and a better health and care experience • Monitoring progress and achievement of goals with individuals by reviewing and, where appropriate, agreeing 'stretch' goals to increase confidence and acknowledgement of progress made • Forming proactive relationships with individuals and their families and carers where appropriate • Demonstrating good local knowledge of the range of voluntary and community services available to support people • Facilitating timely access to appropriate services for individuals through signposting or assisting individuals to navigate appropriate services as required • Promoting health and wellbeing and self-care / self-management approaches to enable greater independence and a better health and care experience • Acting as a key advocate for the individuals as and when required or signposting to advocacy services in that particular area of interest • Contributing to the reduction of preventable A&E attendances and unplanned emergency hospital admissions by supporting and enabling individuals, their family and carers to become better at self-management and accessing self-management support • Undertaking customer feedback and using peoples experience to inform improvements and in future service developments and design. • Lengths of intervention will be assessed through a complexity tool which will establish the complexity of the goals identified and their time impact. • Initiate MyCMC plans with clients as appropriate Additional information: This interim contract is for 12 months (1st August 2021 until 31st July 2022) with a value of £900,000. Rights are reserved to extend for up to a further 12 months (24 months maximum) with an overall potential value of up to £1,802,000. Rights are also reserved to novate this contract, during the life of the new contract, to a local NHS Trust acting as local system leader for this and related service contracts.