Job responsibilities
To promote social prescribing, its role in self-management and the wider determinants of health to members of the PCN and other agencies
Build relationships with staff in GP practices within PCN, attending MDT meetings, giving information and feedback on social prescribing.
Be proactive in 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
Work 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
To ensure ongoing engagement with the PCN to ensure a minimum number of social prescribing attachments occur a year in line with PCN requirements / contractual requirements.
Provide referral agencies with regular updates about social prescribing, including training for their staff and how to access information to encourage appropriate referrals
Seek regular feedback about the quality of the service and impact of social prescribing on referral agencies
Work closely with PCN and MDT to ensure that the social prescribing referral codes are inputted into clinical systems in line with PCN contract.
To ensure data sharing agreements are in place and adhered to
Be proactive in undertaking community development to encourage self-referrals and connecting with all local communities, particularly those communities that statutory agencies may find hard to reach
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
Work collectively with all local partners to ensure community groups are strong and sustainable
Meet people on a one to one basis, making home visits where appropriate.
To effectively time manage a caseload of clients, and be able to effectively prioritise workload in accordance with needs, priorities and any urgent support required by clients on the caseload and to meet scheduling requirements
Provide 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. Giving people time to tell their stories and focus on what matters to them.
Using person centred strengths based approach, co-produce with the patient their personalised care and support plan to address the patients health and wellbeing needs by introducing or reconnecting people to community groups and statutory services both over the telephone and by accompanying the person.
Facilitate and coordinate activities to support behaviour change and maintenance through building motivation, confidence for change and through setting and supporting the clients to achieve goals
Be a friendly, trusted source of information about health, wellbeing and prevention approaches, enabling the patient to focus on what matters to them
Work with the person, their families and carers and consider how they can all be supported through social prescribing, using local agencies to maximise the package of support
Help people identify the wider issues that impact on their health and wellbeing such as debt, good housing, being unemployed, loneliness, caring responsibilities etc.
Help people maintain or regain their independence through living skills, adaptations, enablement approaches and safeguards
Evaluate how far the actions in the care and support plan are meeting the individuals health and wellbeing needs by undertaking a review at least 6 weekly, using the prescribed health reassessment tools, ensuring that clients have been able to engage with local assets and are receiving appropriate support.
Provide personalised support to individuals, their families and carers to take control of their health and wellbeing, live independently and improve their health outcomes
Develop trusting relationships by giving people time and focus on what matters to them
Take a holistic approach, based on the persons priorities, and the wider determinants of health
Work 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 clients are beyond the scope of the link worker e.g. when there is a mental health need requiring a qualified practitioner.
Deliver interventions using a range of motivational techniques.
Convert social determinant outcomes into health outcomes
Assess, monitor and manage risk including suicidal ideation and safeguarding issues.
Where people may be eligible for a personal health budget, help them to explore this option as a way of providing funded, personalised support to be independent, including helping people to gain skills for meaningful employment, where appropriate.
Collation of and responsibility for accuracy of required dataset in line with commissioner audit requirements.
Work proactively to develop relationships with external providers to facilitate joint case management of clients accessing multiple services.
Draw on and increase 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 work 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.
Educate 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.
Develop, deliver and evaluate training sessions for other PCN Social Prescribers, support PCN Social Prescribers to maximise engagement activities in order to achieve effective attachment rates, and provide strategic support for the PCN Social Prescribing Programme under the direction of the Primary Care Network Co-ordinator
Be an active member of the PCN Social Prescribers action learning set to drive continuous improvement in the Social Prescribing programme.
Support the Primary Care Network Co-ordinator to ensure the requirements of ISO 9001 quality and ISO27001 information security governance are fully met.
