Job responsibilities
1. Take referrals from the PCNs GP practices and multi-disciplinary teams as well as local agencies including pharmacies, wider multi-disciplinary teams, hospital discharge teams, allied health professionals, fire service, police, job centres, social care services, housing associations, and voluntary, community and social enterprise (VCSE) organisations. Self-referral is also encouraged.
2. As a key member of the PCN multi-disciplinary team, provide personalised support to individuals, their families and carers to take control of their health and wellbeing, live independently and improve their health outcomes, developing trusting relationships by giving people time and focus on what matters to me. Take a holistic approach, based on the persons priorities and the wider determinants of health.
3. Co-produce a simple personalised care and support plans to improve health and wellbeing, introducing or reconnecting people to community groups and statutory services.
4. Meet people on a one-to-one basis, making home visits where appropriate within organisations policies and procedures.
5. Manage and prioritise your own caseload, in accordance with the needs, priorities and any urgent support required by individuals. It is vital that you have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when the persons needs are beyond the scope of the link worker role e.g. when there is a mental health need requiring a qualified practitioner.
6. Working closely with the voluntary and community sector, draw on and help to increase the strengths and capacities of local communities, enabling local VCSE organisations and community groups to receive social prescribing referrals.
7. Alongside other members of the PCN multi-disciplinary team, work towards supporting the local VCSE organisations and community groups to become sustainable.
8. Work with commissioners and local partners to identify unmet needs within the community and gaps in community provision.
9. Ensure that community assets are nurtured, through sharing intelligence regarding any gaps or problems identified in local provision.
10. Champion Social Prescribing and support educating non-clinical and clinical staff within their PCN multi-disciplinary teams 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.
11. Build positive relationships that promote a two-way referral process with statutory services, other providers, charities and groups; identify gaps in services for clients.
12. Be proactive in developing strong links with local agencies to encourage referrals, recognising what they need to be confident in the service to make appropriate referrals.
13. Seek advice and support from the GP supervisor and/or identified individual(s) to discuss patient-related concerns (e.g.abuse, domestic violence and support with mental health), referring the patient back to the GP or other suitable health professional if required.
14. Working closely with voluntary sector partners, check that community groups and VCSE organisations meet in insured premises and that health and safety requirements are in place. Where such policies and procedures are not in place, support groups to work towards this standard before referrals are made to them.
15. Support local groups to act in accordance with information governance policies and procedures, ensuring compliance with the Data Protection Act.
16. Work closely within the Multi-Disciplinary Teams and with GP practices within the PCN to ensure that the social prescribing referral codes are inputted into clinical systems (as outlined in the Network Contract DES), adhering to data protection legislation and data sharing agreements.
17. Work sensitively with people, their families and carers to capture key information, enabling tracking of the impact of social prescribing on their health and wellbeing.
18. Encourage people, their families and carers to provide feedback and to share their stories about the impact of social prescribing on their lives to inform case studies.
19. Work closely with the voluntary and community sector to ensure you keep up to date with any developments within the organisation and the wider local voluntary sector.
20. Adhere to organisational policies and procedures within the PCN, including confidentiality, safeguarding, lone working, information governance, and health and safety.
21. Work with your supervising GP to access regular clinical supervision, to enable you to deal effectively with the difficult issues that people present and to undertake continual personal and professional development.
22. Work as part of the healthcare team to seek feedback, continually improve the service and contribute to business planning.
23. The post holder will be expected to take responsibility for self-development on a continuous basis, undertaking on-the-job training as required.
24. Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner.
25. The post holder will ensure they accurately represent the PCN and ensure the values of the PCN are always upheld in carrying out their work
26. Duties may vary from time to time, without changing the general character of the post or the level of responsibility.
Project management and service delivery
The SPLW will support the Clinical Directors and PCN management team in delivering specific projects alongside the Integrated Neighbourhood Team.
Attending PCN management weekly meeting when necessary to discuss ongoing and upcoming projects.
Driving the progress and ensuring the completion of projects in line with the required and agreed outcomes and objectives.
Actively tracking the progress of projects and working alongside PCN business support manager to deliver projects.
Preparing reports on projects and fulfilment of service requirements as required.
Enabling stakeholder engagement across the organisation and with external partners in terms of aligning expectations on project resources and deliverables.