1. Take referrals from anyone in the GP Practice team and from other agencies. Suitable referrals include: • People with one or m.....
1. Take referrals from anyone in the GP Practice team and from other agencies. Suitable referrals include: • People with one or more long-term conditions • People who need support with their mild to moderate mental health • People who are lonely or isolated • People who have complex social needs which affect their wellbeing. 2. Undertake holistic assessments and co-produce a personalised plan with patients, identifying support needs. 3. Support may be: • Level 1 – phone call(s) and signposting to support/information • Level 2 – one face-to-face assessment and personalised plan • Level 3 – up to 6 face-to-face sessions (in exceptional circumstances up to 12 sessions) 4. Provide on-going support to patients to implement their plan 5. Support patients to access local support services, groups, activities, etc 6. Record information on the practice clinical system 7. Integrate Health Champions in working with specific patients 8. Promote Social Prescribing services 9. Encourage volunteers to support Social Prescribing e.g. Helping patients to access local support 10. Work in partnership with local voluntary and community organisations Responsibilities: 1. Referrals • Take referrals from a wide range of agencies, initially working with GP practices within primary care networks, then expanding to pharmacies, 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, etc. • Promoting social prescribing, its role in self-management, and the wider determinants of health. • Build relationships with key staff in GP practices within the local Primary Care Network (PCN), attending relevant meetings, becoming part of the wider network team, giving information and feedback on social prescribing. • Be proactive in developing strong links with all local agencies to encourage referrals, recognising what they need to be confident in the service to make appropriate referrals. • 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. • Provide referral agencies with regular updates about social prescribing, including training for their staff and how to access information to encourage appropriate referrals. • Be proactive in encouraging self-referrals and connecting with all local communities, particularly those communities that statutory agencies may find hard to reach. • Refer patients back to other health professionals/agencies, when what the person needs is beyond the scope of the Link Worker role – e.g. when there is a mental health need requiring a qualified practitioner 2. Provide Personalised Support • Provide personalised support to individuals, their families and carers to take control of their wellbeing, live independently and improve their health outcomes. Develop trusting relationships by giving people time and focus on ‘what matters to me’. Take a holistic approach, based on the person’s 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. • Manage and prioritise caseload, in accordance with the needs, priorities and any urgent support required by individuals. • Meet people on a one-to-one basis, making home visits where appropriate within organisations’ policies and procedures. Give people time to tell their stories and focus on ‘what matters to me’. Build trust with the person, providing non-judgmental support, respecting diversity and lifestyle choices. • Help people identify the wider issues that impact on their health and wellbeing, such as debt, poor housing, being unemployed, loneliness and caring responsibilities. • Work with the person, their families and carers and consider how they can all be supported through social prescribing. • Where appropriate, physically introduce people to community groups, activities and statutory services, ensuring they are comfortable. • Follow up to ensure they are happy, able to engage, included and receiving good support. • 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. 3. Support Community Groups and VCSE Organisations to Receive Referrals • Forge strong links with local VCSE organisations, community and neighborhood level groups, utilising their networks and building on what’s already available to contribute to a menu of community groups and assets. • Develop supportive relationships with local VCSE organisations, community groups and statutory services, to make timely, appropriate and supported referrals for the person being introduced. • Identify any gaps in service/activity provision and highlight these to the relevant staff. 3. Encourage Volunteering • Encourage people who have been connected to community support through social prescribing to volunteer and give their time freely to others, in order to build their skills and confidence, and strengthen community resilience. • Encourage ‘buddying support’ for people starting new activities • Encourage people, their families and carers to provide peer support and to do things together, such as setting up new community groups or volunteering. 4. Data capture and Information • 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. • Input data onto the GP Practice clinical system using the Social Prescribing Template. • Encourage people, their families and carers to provide feedback and to share their stories about the impact of social prescribing on their lives. • Support referral agencies to provide appropriate information about the person they are referring. • Provide appropriate feedback to referral agencies about the people they referred. • Provide data and reports as required. • Partake in audit as directed by the PCN or SWGP Professional development • Undertake continual personal and professional development. • Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety. • Engage in regular ‘clinical supervision’, to enable you to deal effectively with the difficult issues that people present.
