The Enfield Integrated Proactive Care Service is an Enfield Community Services (ECS) Multi-Disciplinary Team (MDT) within the Royal Free London NHS Foundation Trust, operating under the North Middlesex University Hospital (NMUH) unit. The service provides coordinated, person-centred support and interventions for residents living with long-term health conditions and/or frailty, helping them to proactively manage their health and wellbeing through an integrated approach to care.
Working collaboratively with the local authority, acute hospital
trusts, primary care services, and the voluntary sector, the MDT delivers
integrated, person-centred care to Enfield residents who are registered with an Enfield GP, helping to improve health outcomes and support individuals to remain independent within their communities.
The successful candidate will join an ambitious and inclusive partnership that is helping to shape the future of integrated care in Enfield. Working closely with clinicians, community partners, and system leaders, you will play a key role in supporting residents through a more connected, preventative, and person-centred approach to care.
This role offers an exciting opportunity to further develop the Enfield Proactive Care Service Multi-Disciplinary Team (MDT) model and contribute to the design and delivery of an exemplary Integrated Neighbourhood Team (INT).
Main duties of the job
1 . Facilitating Access to Local Services
- Receive and process referrals from GPs and other members of the multidisciplinary team (MDT) for individual patients.
- Assess patients' needs in line with referral criteria and GP guidance, signposting them to appropriate health, social care, voluntary sector, and community services available within the borough.
- Support individuals to access services and activities that promote health, wellbeing, independence, and social inclusion, including both funded and self-funded options.
- Identify unpaid carers and assist them in accessing relevant support services and resources.
- Work collaboratively with volunteers, supporting their involvement and adhering to established procedures and best practices for volunteer engagement.
- Provide general information regarding potential benefit entitlements and refer individuals to specialist welfare advice services where appropriate.
- Develop personalised support plans outlining recommended services and access routes, ensuring relevant information is shared with GPs, carers, and other professionals involved in the individual's care.
- Maintain comprehensive knowledge of local services, community resources, and eligibility criteria, keeping up to date with service developments and changes.
- Promote awareness among GPs and healthcare professionals of the range of community-based services available and how these can be accessed.
The Enfield Integrated Proactive Care Service is an Enfield Community Services (ECS) Multi-Disciplinary Team (MDT) within the Royal Free London NHS Foundation Trust, operating under the North Middlesex University Hospital (NMUH) unit. The service provides coordinated, person-centred support and interventions for residents living with long-term health conditions and/or frailty, helping them to proactively manage their health and wellbeing through an integrated approach to care.
Working collaboratively with the local authority, acute hospital
trusts, primary care services, and the voluntary sector, the MDT delivers
integrated, person-centred care to Enfield residents who are registered with an Enfield GP, helping to improve health outcomes and support individuals to remain independent within their communities.
MAIN DUTIES AND RESPONSIBILITIES
The post holder will offer World Class Care to service users, staff, colleagues, clients and patients alike so that everyone at the Royal Free can feel:
1 . Facilitating Access to Local Services
- Receive and process referrals from GPs and other members of the multidisciplinary team (MDT) for individual patients.
- Assess patients' needs in line with referral criteria and GP guidance, signposting them to appropriate health, social care, voluntary sector, and community services available within the borough.
- Support individuals to access services and activities that promote health, wellbeing, independence, and social inclusion, including both funded and self-funded options.
- Identify unpaid carers and assist them in accessing relevant support services and resources.
- Work collaboratively with volunteers, supporting their involvement and adhering to established procedures and best practices for volunteer engagement.
- Provide general information regarding potential benefit entitlements and refer individuals to specialist welfare advice services where appropriate.
- Develop personalised support plans outlining recommended services and access routes, ensuring relevant information is shared with GPs, carers, and other professionals involved in the individual's care.
- Maintain comprehensive knowledge of local services, community resources, and eligibility criteria, keeping up to date with service developments and changes.
- Promote awareness among GPs and healthcare professionals of the range of community-based services available and how these can be accessed.
2. Personalisation Support
- Support individuals in accessing Community Care Assessments and Carers' Assessments where appropriate.
- Monitor progress following referrals and liaise with local authority staff and other agencies to help ensure timely access to assessments and support.
- Provide general guidance regarding personal budgets and available options, including Direct Payments and associated choices, where applicable.
- Signpost individuals and carers to suitable free, voluntary, community, and statutory services regardless of eligibility for council-funded support.
- Empower individuals to make informed decisions about their care, support arrangements, and available community resources.
3. Care Coordination and Integrated Working
- Liaise effectively with a range of healthcare, social care, and voluntary sector professionals involved in an individual's care to promote a coordinated and person-centred approach.
- Support integrated care planning and case management initiatives that enable patients to manage their health and wellbeing effectively and reduce avoidable hospital admissions.
- Actively participate in practice-based MDT meetings and case discussions.
- Recognise situations requiring urgent intervention or escalation and promptly alert the appropriate healthcare professional or service.
- Foster effective communication between agencies to ensure seamless support for patients and carers.
