CHAW PCN Social Prescriber Link Worker

Job Purpose Social prescribing empowers people to take control of their health and wellbeing through referral to link worker who gives time, focuses on what matters to the patient and takes a holistic approach to an individuals health and wellbeing, connecting people to community groups and statutory services for practical and emotional support. The Social Prescribing Link Worker and will be embedded within CHAW Primary Care Network multi-disciplinary teams to provide personalised support to individuals, their families and carers to take control of their wellbeing, live independently and improve their health outcomes. The Social Prescribing Link worker will: Develop trusting relationships by giving people 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 people 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 Be able to engage groups statutory agencies find difficult to engage with. Job Description As care social prescriber your key responsibilities will include, but not be limited to: Main duties 1. As a member of the Primary Care Network (PCN) team, social prescribing link worker will establish 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. 2. To promote social prescribing, its role in self-management and the wider determinants of health to members of the PCN and other agencies 3. Build relationships with staff in GP practices within PCN, giving information and feedback on social prescribing 4. Be proactive in developing strong links with all local agencies in line with the social prescribing implementation plan to encourage referrals recognizing what they need to be confident in the service to make appropriate referrals 5. 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 6. 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 7. Seek regular feedback about the quality of the service and impact of social prescribing on referral agencies 8. Work closely with PCN and MDT to ensure that the social prescribing referral codes are inputted into clinical systems in line with PCN contract. 9. To ensure data sharing agreements are in place and adhered to 10. 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 11. Forge strong links with local VCSE organisations, community and neighbourhood level groups utilizing their networks and building on what is already available to create a menu of community groups and assets 12. Meet people on a one to one basis. 13. 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 14. Provide 1:1 support to assess patients current assets/needs using the agreed evidence based assessment tools including Dialog 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. 15. 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. 16. 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 17. Be a friendly, trusted source of information about health, wellbeing and prevention approaches, enabling the patient to focus on what matters to them 18. 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 19. Help people identify the wider issues that impact on their health and wellbeing such as debt, good housing, being unemployed, loneliness, caring responsibilities etc. 20. Help people maintain or regain their independence through living skills, adaptations, enablement approaches and safeguards 21. Develop trusting relationships by giving people time and focus on what matters to them 22. Take a holistic approach, based on the persons priorities, and the wider determinants of health 23. 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 24. Deliver interventions using a range of motivational techniques 25. Convert social determinant outcomes into health outcomes 26. Assess, monitor and manage risk including suicidal ideation and safeguarding issues. 27 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 28. 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 General Work Related Expectations 1. To work within CHAWs Values, Ethos and Vision. 2. To work in accordance with all Practices Policies and Procedures 3. To identify and attend training as required 4. To work in accordance with all relevant legislation 5. To undergo regular supervision and an annual appraisal and 360 feedback 6. To undertake any other duties as required, appropriate to the post 7. To work as part of the healthcare team to seek feedback, continually improving the service and contributing to business planning Health and Safety All our PCN staff 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 toyour 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 weaknessesthat 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 CHAW practices information governance policies and Procedures. Confidentiality Working within CHAW 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.

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