Job Overview
The High Intensity Use (HIU) Care Co-ordinator is responsible for managing and supporting individuals with complex needs within high-intensity service settings. This role involves coordinating care plans, liaising with multidisciplinary teams, and ensuring that service users receive tailored support to promote their wellbeing and independence. The position offers an opportunity to make a meaningful difference in the lives of vulnerable individuals through organised, compassionate, and professional care management. Candidates should possess strong organisational skills and experience working within office environments.
The role will require engagement with clinical staff to coordinate care for individuals referred and identified by the service. The aim of the service will be to provide positive health and well-being outcomes, through addressing non-medical/social issues in their life, such as housing, debt or isolation. The post holder is responsible for facilitating discussions between Primary Care, hospital and community services. The post holder will be required to manage patient caseloads and advise on improvements, which will be used to deliver measurable outcomes for the benefit of patients, staff and the public. The role requires extensive liaison with statutory and non-statutory services, to review and support the flow of referrals into the service. The main focus client groups include individuals experiencing homelessness, mental health and medical, social presentations, who may not be accessing scheduled services and therefore relying heavily on unscheduled services.
2.0 REPORTING STRUCTURE:
This role will support the High Intensity User scheme and be accountable to the Primary Care/Community Directorate management structure.
3.0 KEY WORKING RELATIONSHIPS:
Service set-up alignment Work with the High Intensity Use workforce and stakeholders across the healthcare system to implement referral and feedback mechanisms
- Develop a comprehensive knowledge of wider support services for people with high support needs including; social isolation, wellbeing, housing, unemployment, welfare benefits.
- Extend and develop the menu of services prescribed in the form of a directory, and develop and maintain systems to keep accurate records relating to the delivery of HIU service
- Liaise with health professionals and establish relationships with existing services, to increase visibility of the project and to ensure information is up-to-date and relevant
- Support a robust patient flow process from referral to delivery of outcomes for the HIU cohort
- To create appropriate tools that enable effective referral and client engagement. Develop and implement a process to give feedback to referrers
- Report risks and implement actions as directed by the line manager /NWL HIU Programme
- To work with healthcare IT systems to ensure appropriate referral and ongoing client management processes are put in place
- To arrange, and coordinate administrative support for the service’s regular borough-based HIU multidisciplinary team meetings
- Support the communication strategy for HIU services to ensure all stakeholders are informed and aware of the project and their roles within it
- Be an advocate for potential barriers and stigma associated with this vulnerable cohort to promote equality, diversity and safeguarding service-wide
4.0 KEY RESULTS AREAS
Key partners and communication
- Develop excellent working relationships with the all partners, wider service networks including the High Intensity Use service teams, voluntary sector, GP practices, adult social care, hospitals, community pharmacists and other members of the MDT and the NWL HIU Programme Build and maintain effective relationships with Information, Advice and Guidance Services
- Share learnings from the project with community based staff to promote safe practice and sustainability
- Maintain good communication with clients and, where appropriate, their families/carers
- Present highly complex information about the project, initiatives and service providers to a wide range of stakeholders in a formal setting
- To produce marketing materials, attend event and outreach where necessary to promote the service
- Is able to recognise personal limitations and refer to more appropriate colleague(s) when necessary
5.0 SERVICE DELIVERY
- Work with commissioner colleagues and the wider HIU staff workforce, to support a review of local demand for this cohort (i.e. Primary Care and A&E services)
- Act as the central point of contact for all referrals to the High Intensity User community/Primary Care HIU service aspect
- Provide information, advice and guidance to referred stakeholders including signposting where appropriate
- Support clinical staff to develop and upload personalised plans with clients to IT systems (i.e. Universal Care Plans, personalised care plans)
- Develop and maintain a client database
- Engage with Harrow GP practices and Primary Care Networks on a regular basis
- To monitor developments within Primary Care and for HIU services at a national-level and to ensure that this is fed in, where possible to local activity.
- Adhere to all relevant internal policies and procedures and ensure compliance with data Protection, Health and safety and safeguarding policy and best practice
- To operate in a highly political and sensitive environment
- Constantly strive for providing efficient, high quality care to identify underlying issues relating to demand and barriers for patients
- Appropriately handle confidential and sensitive patient information
- Determine links to existing projects, identifying interdependencies across projects/functions, potential impacts on wider organisation, resource requirements – building in contingency as necessary
- Where required, support the HIU workforce to produce tools and models for client engagement that address wellbeing, asset mapping, signposting, empowerment, and self-help
7.0 REPORTING MANAGEMENT
Monitoring, report and evaluation
- Plan, develop and implement methods and processes with the HIU workforce, to support the evaluation of service demand and patient outcomes
- Monitor and evaluate the effectiveness of the service against agreed targets
- Support the development of quarterly and annual reports for the service, including information that demonstrates the qualitative and quantitative benefits delivered
- Document any gaps in service provision for the High Intensity Use cohort
- Drafting reports and summarising issues, patient outcomes, and providing progress reports for NWL HIU Programme (i.e. NWL Integrated Care Board)
- Collate as required, qualitative and quantitative information to highlight issues and risks
Scope and Purpose of Job Description
A job description does not constitute a ‘term and condition of employment’. It is provided only as a guide to assist the employee in the performance of their job. NWL ICB is a fast moving organisation and therefore changes in employees’ duties may be necessary from time to time. The job description is not intended to be an inflexible or finite list of tasks and may be varied from time to time after consultation/discussion with the postholder.
Responsibilities
- Develop, implement, and review personalised care plans for service users with high-intensity needs.
- Coordinate communication between healthcare professionals, social workers, and other relevant agencies to ensure seamless service delivery.
- Maintain accurate and up-to-date documentation of care activities and progress reports.
- Organise appointments, meetings, and reviews related to individual care plans.
- Provide administrative support including scheduling, data entry, and record keeping using office software systems.
- Monitor service user progress and escalate concerns to appropriate team members promptly.
- Support service users in accessing community resources and activities to promote independence.
- Contribute to team meetings by providing insights on care coordination efforts and service user needs.
Experience
- Prior experience working within a healthcare or social care environment is desirable.
- Care Coordination experience is essential, demonstrating proficiency in administrative tasks such as scheduling, record management, and communication.
- Experience & Knowledge of high-intensity support services or mental health settings is advantageous but not mandatory.
- Strong organisational skills with the ability to manage multiple priorities efficiently.
- Excellent communication skills, both written and verbal, with a compassionate approach towards service users.
- Ability to work collaboratively within multidisciplinary teams while maintaining professional boundaries.
This role offers a rewarding opportunity for dedicated individuals committed to delivering high-quality support services in a structured environment.
Pay: £32,073.00-£39,043.00 per year
Work Location: In person
