About this role
Job summary
Following the recent NHS 10year plan, Lewisham is transforming care by establishing Integrated Neighbourhood Teams (INT). The INTs are designed to deliver coordinated, community-based care and support.
To ensure a controlled and effective rollout, the initial focus of INTs will be on supporting patients with three or more cardiovascular long-term conditions (LTCs) including diabetes, atrial fibrillation, chronic kidney disease and hypertension.
Residents accessing the service will receive holistic support that addresses both physical and social factors affecting their lives. This includes:
A comprehensive Getting to Know You Assessment conducted by the INT Caseworker to identify health and social needs. A Health Review with a Clinical Pharmacist to manage cardiovascular LTCs Access to the Lifestyle Medicine Service, offering personalised support for healthier living from a Health and Wellbeing Lifestyle Coach Group consultations to share experiences, learn from others, and receive expert advice Support with social challenges, such as housing, finances, or lonelinessbecause wellbeing goes beyond just health
We are looking for an individual with a passion for providing proactive, person-centred care to work as an INT Caseworker within the Lewisham Community for the North Lewisham PCN.
Main duties of the job
The INT Caseworker will play a central role in supporting the implementation and delivery of Lewisham NHS 10 -Year Plan for integrated neighbourhood working.
The role holder will focus on improving outcomes for residents by streamlining care pathways, managing complex caseloads, conducting holistic assessments, and ensuring individuals receive the right support through effective signposting and coordination.
Acting as the critical link between health, social care, and community services, the INT Caseworker will ensure seamless, person-centred care that tackles health inequalities.
About us
North Lewisham Primary Care Network (NLPCN) is one of the largest PCNs in Lewisham and has a very diverse population made up of 10 GP Practices serving a population of around 91,000 patients.
Health inequality impacts our patients: North Lewisham has higher than average levels of deprivation and BAME populations and poorer health outcomes.
NLPCN is committed to tackling health inequality as a priority. We have developed a program of work to improve trust and engage with our local community, training our GP surgeries and staff to improve access for patients, improving our communication to patients about service changes and health promotion and improving the monitoring of those suffering from health inequality to drive our strategy.
The Waldron is a health centre and a community hub promoting health and wellbeing activities.
Job description Job responsibilities
Duties & Responsibilities
Population Health and Caseload Management
Analyse and assess population health data to identify high-priority patients or cohorts for INT intervention using e.g. EMIS Web, Microsoft Excel, AccuRx, Ardens manager and other systems as needed. Manage and maintain the INT caseload, ensuring efficient prioritisation and monitoring of patient progress. Collaborate with multidisciplinary teams (MDTs) to coordinate and manage patient support plans. Holistic Patient Assessments
Conduct holistic face to face assessments with patients to understand their health, social care, and personal support needs. Conducting blood pressure, weight, height and pulse check Conducting blood tests if needed training can be provided Work with patients to set SMART achievable goals and identify solutions that promote independence and well-being. Use an evidence-based approach to recognise patient priorities and encourage self-management wherever possible. Facilitate group consultations for long term conditions including Type 2 Diabetes, Atrial Fibrillation, Chronic Kidney Disease and Hypertension. Provide follow up holistic assessments prior to patient discharge from the INT service Service Linkage and Signposting
Provide effective signposting for low-intervention patients to one-off or community-based support services. Act as a coordinator between various services, including primary care, secondary care, social care, mental health, and voluntary sector organisations. Ensure patients are connected with the most appropriate support resources to address their individual needs. Integrated Working and Coordination
Participate in INT and MDT meetings to represent patient needs and advocate for their voice in care planning. Actively support care coordination by liaising with GPs, hospital teams, social care, and community organisations. Maintain accurate and up-to-date records of interventions, referrals, and progress in patient care plans. IT and Communication
Utilise digital tools and IT systems to streamline communication and record patient data accurately. Use Microsoft excel efficiently in maintaining a patient caseload Manage INT PCN email inbox using Microsoft Outlook Address interface challenges between IT systems to ensure seamless information sharing across teams and organisations. Promote digital inclusion by supporting patients in accessing online services and tools where applicable. Community Engagement and Partnership
Build strong relationships with local voluntary and community organisations to enhance the range of support available to patients. Work with partnership organisations to refine and improve pathways, ensuring effective collaboration. Gather feedback from patients and partners to continuously improve service delivery and address local needs. Working Relationships and Contacts
Lifestyle Medicine Community of Practice Lead INT Clinical Lead Pharmacists Integrated Neighbourhood Core Team General Practitioners (GPs) Social Prescribing Link Workers Care Coordinators Community Link Workers Other health professionals within the PCN Network Contract Directed Enhanced Service (DES)
The post holder is expected to work core hours but should also be flexible around service needs, which may include some evenings and weekends.
Person Specification
Experience Essential
Previous experience in health, social care, or community coordination roles Familiarity with face to face holistic assessment approaches and patient-centred care planning Understanding of population health management and tackling health inequalities Competence in completing NHS Health Checks and Diabetes 8 Care Processes including blood pressure, weight, height and pulse checks
Desirable
Competence in completing phlebotomy Knowledge of the Lewisham area and its health and care landscape Experience with working with those with Learning Disabilities and SMI
Other Essential
Meets DBS reference standards and has a clear criminal record, in line with the law on spent Willingness to work flexible hours when required to meet work demands Ability to travel across the locality on a regular basis.
Qualities and Attributes Essential
Ability to listen, empathise with people and provide person- centred support in a non- judgemental way Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity Commitment to reducing health inequalities and proactively working to reach people from all communities Able to support people in a way that inspires trust and confidence, motivating others to reach their potential Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders Ability to work as part of a team and operate in a way that is consistent with the organisational values Ability to maintain effective working relationships and to promote collaborative practice with all colleagues Ability to identify risk and assess/manage risk when working with individuals Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the link worker role Able to work from an asset-based approach, building on existing community and personal assets Able to provide leadership and to finish work tasks Ability to maintain effective working relationships and to promote collaborative practice with all colleagues Commitment to collaborative working with all local agencies Demonstrates personal accountability, emotional resilience and works well under pressure Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines High level of written and oral communication skills Ability to work flexibly and enthusiastically within a team or on own initiative Understanding of the needs of small volunteer-led community groups and ability to support their development
Qualifications Essential
Good general education with English and Maths to GCSE standard or equivalent NVQ Level 3, Advanced level or equivalent qualifications or working towards this level Demonstrable commitment to professional and personal development
Desirable
Completion of a higher education certificate or diploma which has included public contact through internship, volunteer experience, or other experience.
Knowledge and Skills Essential
Strong organisational skills to manage caseloads and prioritise tasks effectively Excellent interpersonal and communication skills for working with patients, families, and multidisciplinary teams Analytical skills to assess population health data and identify target groups for intervention Ability to conduct person-centred assessments and create individualised care plans Knowledge of the health and social care system, including voluntary sector services Proficiency in IT systems and digital tools for care coordination and reporting including EMIS Web, Microsoft Excel/Word/Outlook and AccuRx Problem-solving skills to address various challenges
Desirable
Knowledge of basic health promotion and protection Knowledge of the NHS and broader services Knowledge of Local Languages
Disclosure and Barring Service Check This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Employer details Employer name North Lewisham Primary Care Network
Address Waldron Health Centre, Ground Floor, Suite 1
Amersham Vale, New Cross
London
SE14 6LD
United Kingdom
Employer's website https://www.northlewishampcn.nhs.uk/ (Opens in a new tab)