Social Prescriber/Care Coordinator

Job description

Job responsibilities

Proactively engage people into the service using a variety of approaches including referrals from GP practice/PCN staff as well as a wide range of other agencies i.e. hospital discharge teams, allied health professionals, social care services and voluntary, community and social enterprise (VCSE) organisations.

Deliver a service that is person centred and flexible focusing on peoples personal goals and strengths.

Provide personalised support to individuals, their families, and carers to take control of their wellbeing, live independently and improve their health.

Develop trusting relationships by giving people time and focus on what matters to them.

Adopt a holistic approach, based on the persons priorities, and the wider determinants of health.

Co-produce a personalised support plan to improve health and wellbeing, introducing or reconnecting people to community groups and statutory services as appropriate.

Deliver a range of direct interventions dependant on the individual needs.

Use person centred approaches to assess, manage and report risk &/or vulnerability with the individual in line with Mid Dorset Primary Care Network policies and procedures & in partnership with the practice location to which they are contracted to work.

Collect and record client progress and outcomes. Taking into consideration qualitative and quantitative data.

Manage and prioritise their own caseload, in accordance with the needs, priorities and support required by individuals on the caseload.

Where required and as appropriate, refer people back to other health professionals within the network & wider NHS.

Provide practice with regular updates about social prescribing to encourage appropriate referrals.

Develop supportive relationships between statutory and VCSE organisations to make timely & appropriate referrals for the person being introduced.

Engage with social prescribing lead and other social prescribers across the PCN to share information & ideas.

Complete all mandatory training & maintain a continuing personal development (CPD) plan

Adhere to the standard operating procedure put in place by the primary care network (PCN)

Adhere to data protection legislation and data sharing agreements.

Work closely with and build relationships with key members of GP practice and PCN staff and attending relevant meetings.

Seek regular feedback about the quality of service and impact of social prescribing on the practice & wider referral agencies.

Promote client involvement in the management of the service

Work as part of the multi-disciplinary team.

Support the Practice in the management of the Practice Population in relation to health initiatives e.g., flu/Covid/pneumonia clinics/practice-based screening.

Support the INT with long term conditon reviews and dementia care planning, accessing and reviewing Population Health Management data.

Communicate politely and effectively with patients, carers, and colleagues and to support the provision of a seamless co-ordinated multidisciplinary service, working collaboratively with clinical colleagues and other agencies and valuing people as active participants in the planning and management of their own health and wellbeing.

At all times, to maintain the highest standards of behaviour, to comply with and follow practice and CQC policies, protocols, and procedures, including information governance, health and safety, equality, and diversity and to report any breach or suspected breach immediately.

To act in a key role for those people who have been identified as at risk of repeated unplanned hospital admissions or long-term care e.g., someone who is socially isolated and is frail, whose clinical and non-clinical need require support, working closely with the practice wellbeing team.

Support the care co-ordinator and INT lead in the organisation and administration of the INT to minimise the demands upon the team, including meeting management, ordering equipment, maintaining vulnerable adult lists and supporting applications for funding.

Work alongside the surgeries carers lead to provide support to carers, including, initial information, onward referral, organising carers clinics, and identifying high risk carers on the surgerys register. You will also be responsible for developing holistic anticipatory care plans including prevention of carer strain.

To undertake any other activities that may from time to time be reasonably requested by the Partners or surgery Management Team.

Person Specification

Experience

Essential

• General understanding of social prescribing and wellbeing
• Good understanding on the importance of social needs and their impact on health
• General understanding of community services and personalised care
• Knowledge of what is available in the not-for-profit/voluntary sector locally and nationally to assist people
• Good knowledge and understanding of interventions and behavioural motivational change methods
• Proven experience of working with the general public in a similar role
• Previous experience of providing structured support and advice to others
• Experience of working with vulnerable adults
• Empathic and caring; sensitive to peoples life stages, concerns and problems
• Motivated to achieve good outcomes for people/clients
• Excellent verbal and written communication skills
• Good IT skills, able to use relevant Office packages (Word, Excel, Databases and Outlook for e-mail/calendar)
• Organised with effective time management skills
• Able to problem solve, analytical skills
• Able to follow policies and procedures effectively
• Able to maintain confidentiality at all times
• Good inter-personal and customer care skills
• Positive approach, calm under pressure
• Flexible in approach, willing to try new/different techniques/approaches
• Able and willing to travel to different PCN sites and other locations and to attend a wide variety of meetings, training events etc., some of which are not easily accessible by public transport

Desirable

• Educated to GCSE level or equivalent
• Health and Wellbeing qualification or equivalent experience
• NVQ Level 3, advanced level or equivalent or working towards accredited NHSE/I e-learning health platform training modules 1-6.
• Coaching qualification Experience of working in a similar healthcare organisation or in the leisure industry/voluntary sector or in education or similar
• Experience working in a community navigator/bridging type role.
• Previous experience of delivering lifestyle change interventions
• Competent in the use of clinical record systems and clinical record keeping
• Previous experience of SystmOne

Qualifications

Essential

• GCSE grades grade C or 4 above English
• Qualification in IT

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

Mid Dorset Primary Healthcare Ltd

Address

Puddletown Surgery

Athelhampton Road

Puddletown

Dorchester

Dorset

DT2 8FY

Employer's website

https://www.mid-dorsetpcn.co.uk (Opens in a new tab)