JOB SUMMARY:

Working within an integrated model of care to support the health and wellbeing of patients working closely with GPs, and multi-agency teams to achieve:

• Holistic care planning, how needs can be met by services and other opportunities available in the community and the co-ordination of input
• Information/advice about a range of services to promote health and wellbeing and maintain independence within communities
• Reducing demand on statutory services and to combat unnecessary GP appointments

PURPOSE OF THE ROLE:

Social prescribing empowers people to take control of their health and wellbeing through referral to non-medical ‘link workers’ who give time, focus on ‘what matters to me’ and take a holistic approach, connecting people to community groups and statutory services for practical and emotional support. Link workers support existing groups to be accessible and sustainable and help people to start new community groups, working collaboratively with all local partners.
Social prescribing can help to strengthen community resilience and personal resilience and reduces health inequalities by addressing the wider determinants of health, such as debt, poor housing and physical inactivity, by increasing people’s active involvement with their local communities. Social Prescribing particularly works for people with long-term conditions (including support for mental health), for people who are lonely or isolated, or have complex social needs which affect their wellbeing.

KEY RESPONSIBILITIES:

• Enabling access to local services, including personalisation support:
• Take referrals from GPs and other clinical staff.
• Develop knowledge of local services to enable the individual to access a range of services to meet their needs and ensure individuals are engaged and connected with their local community and other organisations to make best use of resources.
• Assess how a patient’s health and wellbeing needs can be met by services and other opportunities that are available in the community.
• Produce a simple personalised care plan to address the patient’s health and wellbeing needs by introducing or reconnecting people to community groups or statutory services.
• Evaluate how actions in the care and support plan are meeting the individual’s health and wellbeing needs.
• 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 person’s priorities and the wider determinants of health.
• Need to manage and prioritise their own caseload in accordance with the health and wellbeing needs of their population and refer people back to other health professionals within the PCN.
• Increase the strengths and capacities of local communities, enabling local voluntary, community and social enterprise organisations (VCSE) and community groups to receive social prescribing referrals.
• Work collaboratively with all local partners to contribute towards supporting local VCSE organisations and community groups to become sustainable through sharing intelligence regarding any gaps or problems identified in local provision with commissioners and local authorities.
• Inform and advise GPs, and primary care staff, either written or verbally, about what services are available within the community and how and when patients can access them.

GENERAL RESPONSIBILITIES:

• Be a champion to promote co-ordinated care and support for all, providing regular updates.
• Consider how to introduce best practice already being developed through other local service providers.
• Work collaboratively with the other Social Prescribers.
• Take part in Mosaic Healthcare PCN events and activities as agreed.
• Establish strong links with other PCN staff and contribute to the wider aims and objectives of the organisation.
• Work in accordance with the organisations policies and procedures.
• Attend training courses as required.
• To carry out any other duties as may be reasonably required from time to time.