Social Prescribing Link Worker

Job description

Job responsibilities

The post holder will:

Develop trusting relationships by giving patients time and focusing on what matters to them

Take a holistic approach, based on the persons priorities, and the wider determinants of health

Co-produce a personalised care and support plan to improve health and wellbeing

Introduce or reconnect patients to community groups and services, both over the phone and in person

Evaluate the individual impact of a persons wellness progress

Record referrals within GP clinical systems using the national SNOMED social prescribing codes and complete case management notes on Pathways systems

Support the delivery of the comprehensive model of personalised care

Draw on and increase the strengths and capacities of local communities, enabling local VCSE organisations and community groups to receive social prescribing referrals

Critically analyse referral trends on a regular basis, along with referrer and patient behaviours, generating development plans to guide future referral activity

Draw together reports for the PCN on how, through social prescribing, the service has reduced avoidable patient demand in GP practices and/or reduced A&E attendance and hospital admissions

MAIN DUTIES:

The post holders key responsibilities will include, but not be limited to:

Establishing referral routes and taking referrals from the PCNs members, expanding from to take referrals from a wide range of agencies in line with PCN requirements

Promoting social prescribing, its role in self-management and the wider determinants of health to members of the PCN and other agencies

Building relationships with staff in GP practices within PCN, giving information and feedback on social prescribing

Proactively developing strong links with all local agencies in line with the social prescribing implementation plan to encourage referrals recognising what they need to be confident in the service to make appropriate referrals

Working in partnership with all local agencies to raise awareness of social prescribing and how partnership working can reduce pressure on statutory services, improve health outcomes and enable a holistic approach to care

Ensuring ongoing engagement with the PCN to guarantee a minimum number of social prescribing encounters occur a year in line with PCN requirements / contractual requirements

Providing referral agencies with regular updates about social prescribing, including training for their staff and how to access information to encourage appropriate referrals

Seeking regular feedback about the quality of the service and impact of social prescribing on referral agencies

Working closely with PCN and MDT to ensure that the social prescribing referral codes are inputted into clinical systems in line with PCN contract

Ensuring data sharing agreements are in place and adhered to

Proactively undertaking community development to encourage self-referrals and connecting with all local communities, particularly those communities that statutory agencies may find hard to reach

With guidance and support from Warrington Disability Partnership, forge strong links with local VCSE organisations, community and neighbourhood level groups utilising their networks and building on what is already available to create a menu of community groups and assets

Working collectively with all local partners to ensure community groups are strong and sustainable

Meeting patients on a one to one basis, making home visits where appropriate

Effectively time managing a caseload of patients and being able to effectively prioritise workload in accordance with needs, priorities and any urgent support required by patients on the caseload and to meet scheduling requirements

Providing 1:1 support to assess patients current assets/needs using the agreed evidence-based assessment tools including Patient Activation Measure, ONS to holistically identify how a patients health and wellbeing needs can be met by services and other opportunities available in the community

Using person centred strengths based approach, co-producing with the patient their personalised care and support plan to address the patients health and wellbeing needs by introducing or reconnecting patient to community groups and statutory services both over the telephone and by accompanying the patient

Facilitating and coordinating activities to support behaviour change and maintenance through building motivation, confidence for change and through setting and supporting the patients to achieve goals

Being a friendly, trusted source of information about health, wellbeing and prevention approaches, enabling the patient to focus on what matters to them

Working with the patient, their families and carers and consider how they can all be supported through social prescribing, using local agencies to maximise the package of support

Helping patients identify the wider issues that impact on their health and wellbeing such as debt, housing, unemployment, loneliness, caring responsibilities etc.

Helping patients maintain or regain their independence through living skills, adaptations, enablement approaches and safeguards

Evaluating how far the actions in the care and support plan are meeting the individuals health and wellbeing needs by undertaking regular reviews, using the prescribed health reassessment tools, ensuring that patients have been able to engage with local assets and are receiving appropriate support

Taking a holistic approach, based on the persons priorities, and the wider determinants of health

Working collaboratively with local agencies/primary care to maximise the potential of health outcomes for patients, referring back to members of the PCN where the needs of the patients are beyond the scope of the link worker e.g., when there is a mental health need requiring a qualified practitioner

Delivering interventions using a range of motivational techniques

Converting social determinant outcomes into health outcomes

Assessing, monitoring and managing risk including suicidal ideation and safeguarding issues

Helping patients, where applicable, to understand personal health budgets as a way of providing funded, personalised support to be independent, including helping patient to gain skills for meaningful employment, where appropriate

Collation of and responsibility for accuracy of required dataset in line with commissioner audit requirements

Working proactively to develop relationships with external providers to facilitate joint case management of patients accessing multiple services

Drawing on and increasing the strengths and capacities of local communities, enabling local VCSE organisations and community groups to receive social prescribing referrals

Alongside other members of the PCN working collaboratively with all partners to contribute towards supporting the local VCSE organisations and community groups to become sustainable and that community assets are nurtured, through sharing intelligence regarding any gaps or problems identified in local provision with commissioners

Educating non-clinical and clinical staff within the PCN on what other services are available within the community and how and when patients can access them. This may include verbal or written advice and guidance

Being an active member of the PCN Social Prescribers action learning set to drive continuous improvement in the Social Prescribing programme

Supporting the PCN to ensure the requirements of ISO 9001 quality and ISO27001 information security governance are fully met

HEALTH AND SAFETY:

All employees have a duty to ensure the health and safety of themselves and others whilst at work. Safe working practices and health and safety precautions are a legal requirement. All accidents must be reported to your line manager. You must participate in accident prevention by reporting hazards and following relevant policies and procedures including moving and handling guidelines.

RISK MANAGEMENT:

All employees are required to contribute to the control of risk and alert their manager to incidents, near misses and weaknesses that may compromise the quality of services and security of information

INFORMATION SECURITY:

All employees have a responsibility and a legal obligation to ensure that information processed for both general public and staff is kept accurate, confidential, secure and in line with the Data Protection Act (1998) and comply with CWW PCN practices information governance policies and Procedures.

CONFIDENTIALITY:

Working within CWW PCN practices you may gain knowledge of confidential matters including in oral, manual and electronic form. Such information must be considered strictly confidential and must not be discussed or disclosed. Failure to observe this confidentiality will lead to disciplinary action being taken against you and possible dismissal.

*This Job Description does not provide an exhaustive list of duties and may be reviewed in conjunction with the post holder in light of service development.

Person Specification

Qualifications

Essential

• Demonstrable commitment to professional and personal development.

Desirable

• Training in motivational coaching and interviewing or equivalent experience.

Experience

Essential

• Experience of supporting patient, their families and carers in a related role (including unpaid work).
• Experience of partnership/collaborative working and of building relationships across a variety of organisations.

Desirable

• Experience of supporting patient with their mental health, either in a paid, unpaid or informal capacity.

Skills and Knowledge

Essential

• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact.
• Knowledge of IT systems, including ability to use word processing skills, emails and the internet to create simple plans.
• Knowledge of motivational coaching and interview skills.

Desirable

• Knowledge of the personalised self-care approach.
• Demonstrate an understanding of the role of the VCSE and peer support

Personal Attributes

Essential

• Ability to listen, empathise with patient and provide person- centred support in a non- judgemental way.
• Able to get along with patient from all backgrounds and communities, respecting lifestyles and diversity.
• Able to support patient in a way that inspires trust and confidence, motivating others to reach their potential.
• Ability to communicate effectively, both verbally and in writing, with patient, their families, carers, community groups, partner agencies and stakeholders.
• Ability to maintain effective working relationships and to promote collaborative practice with all colleagues.
• Ability to work flexibly and enthusiastically within a team or on own initiative.

Other

Essential

• Meets DBS reference standards.

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

MIAA Solutions

Address

Central and West Warrington Primary Care Network

Folly Lane Medical Centre

Warrington

Cheshire

WA50LU

Employer's website

https://cmgeneralpracticejobs.nhs.uk/ (Opens in a new tab)