Social Prescribing Link Worker Vulnerable and Home bound Patients

Job description

Job responsibilities

Take referrals from health care professionals and staff within the Primary Care Network (PCN)

Take a lead role in the development of care for frail, elderly and home bound patients, with the aim of providing proactive care and follow up of home bound patients across St Pauls PCN practices.

Work with other health and care providers to share information, jointly plan care and provide a streamlined, integrated service.

Meet with patients either face to face or conduct appointments/consultations over the phone to help patients.

o assess what matters to them and what support, information, or advice they may need.

To co-produce where necessary a personalised care and support plan with patients to help improve their health and wellbeing.

To work with the PCN Advanced Care Practitioner to support management of Co-morbidities by the patient having a home visit.

When appropriate, actively signpost patients to local services to improve their emotional and physical wellbeing. This will include but not limited to benefits/finances, housing, social isolation, debt, respite, bereavement, and other learning disability support.

To support patients in accessing tools and implementing strategies to help manage their own mental health.

To assist patients to take decisions on what type of support they require that best meets their health and wellbeing needs. This will involve using a range of behavioural change techniques such as motivational interviewing; health coaching and strengths-based approaches to determine their skills, interests.

In partnership complete the most appropriate referral pathway to agencies on behalf of patients, particularly working closely with the complex care at home team.

To accurately record contact with patients through the GP clinical system, Systm One, as well as maintaining other computerized records within the PCN. This will involve reviewing and coding frailty including moderate and Severe.

Be proactive in developing strong links with statutory and voluntary agencies as well as local community groups.

Build relationships with staff within the PCN, attend multi-disciplinary team meetings (MDTs) and help promote social prescribing to staff.

To monitor and manage risk, including suicide ideation and safeguarding issues in line with organisational safeguarding policy.

Represent St Pauls PCN on all relevant statutory and voluntary sector committees, working parties, steering groups and management committees as required by the Operational Director.

Promote good public relations using local media, participating in relevant public events, and organising promotional events for the PCN through the production of publicity material.

Contribute to monitoring and evaluation of services, ensuring that data is captured and recorded via appropriate methods.

To Support the Lead Social Prescriber in any other appropriate duty, including the teams development of our Patient Participation Groups.

There may be, on occasion, a requirement to carry out other tasks; this will depend on factors such as workload and staffing levels.

Person Specification

Experience

Essential

• Previous experience of providing structured support and advice to others

Desirable

• Experience of working with others to obtain successful outcomes for vulnerable adults

Knowledge

Essential

• Good understanding of social prescribing
• Good understanding of the wider determinants of health and how to help reduce health inequalities
• A proven understanding of safeguarding for vulnerable adults and ability to implement relevant policies and procedures

Desirable

• Good understanding of local service provision in the statutory, voluntary and community sector
• Good knowledge and understanding of interventions and behavioural motivational change methods
• Good understanding of mental health conditions and how these can impact a persons wellbeing and the challenges this can present in accessing services.

Skills and abilities

Essential

• Good verbal and written communication skills
• Empathic and caring; sensitive to peoples life stages, concerns and problems
• Good IT skills, able to use relevant Office packages (Word, Excel, Databases and Outlook for e-mail/calendar)
• Readiness to work cooperatively with a range of professionals, agencies, organisations, and individuals
• Ability to motivate
• Ability to adapt, cope under pressure and meet deadlines
• Problem solving skills
• Commitment to working flexibly
• Ability to work individually and as part of a team good use of initiative.
• To maintain confidentiality
• To act professionally at all times

Qualifications

Essential

• 5 GCSEs at grade 4 (c) or above including maths and English

Desirable

• Health, social care or wellbeing qualification or equivalent experience

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

St Paul’s Primary Care Network

Address

St Pauls Medical Centre

121 Swindon Road

Cheltenham

Gloucestershire

GL50 4DP

Employer's website

https://www.stpaulspcn.co.uk/ (Opens in a new tab)