Social Prescriber

The PCN Social prescriber will review all referrals and allocate appropriate referrals - Hold own case load of “complex” cases - Introduce or coordinate an appropriate group support session - Make referrals directly to external providers e.g., DWP, VSC, Help Hub Manage dedicated caseload of complex cases: - Develop trusting relationships, giving individuals time and focus on what matters to them. - Support individuals to identify the wider issues that impact their health and Wellbeing, such as debt, poor housing, unemployment, isolation, and caring responsibilities. - Co-produce a simple personalised care and support plan to improve health and wellbeing. - Where appropriate introduce individuals to appropriate community groups, activities, and statutory services, ensuring they feel comfortable, valued, and respected.
- Hold 1-1 appointment with individuals at the most appropriate location to meet individual needs, making home visits where appropriate within PCN policies and procedures. - Work with individuals their families and carers to maintain or regain independence through living skills, adaptations, enablement, and simple safeguards. - Have an awareness and understanding of when it is appropriate or necessary to refer individuals back to other health professionals/agencies, when there are additional needs such as mental health that requires a trained practitioner. - Where people are eligible for a personal health budget, support them to explore this option as a way of providing funding to enhance personalised support, to be independent and gain skills for meaningful employment, where appropriate.
- Seek advice and support from the GP supervisor to discuss patient related concerns (e.g., abuse, domestic violence, and support with mental health) referring to the GP or other suitable health professional. Support population health management projects: - Work as part of the PCN project team to pilot new ways of working in response to population health data, delivering any aspect relating to social prescribing, and advising on community and voluntary sector services that should be included in the solution - Be proactive in developing strong links with the PCN practice teams to encourage referrals and raise awareness on what other services are available within the community and how patients can access them - Expanding the referral criteria to include wider agencies such as pharmacies, hospital discharge teams, allied health professionals, fire service, job centres, social care services, housing associations, VCSE organisations, the list is not exhaustive. - Work in partnership with all local agencies to educate and raise awareness of social prescribing and how partnership working can reduce pressure on statutory services. - Provide referral agencies with regular updates about social prescribing, including training their staff and how to access information, and seek their feedback - Be proactive in encouraging equality and inclusion, through self-referrals and connecting with all diverse local communities particularly those that statutory agencies may find hard to reach.
- Work with commissioners and local partners to identify unmet diverse needs within the community and gaps in community provision. - Encourage individuals their families and carers to provide peer support and do things together such as setting up new community groups or volunteering. Oversee the data capture, reporting and evaluation for the service - By working sensitively with individuals, their families, and carers, use a suitable evaluation tool to capture key information to demonstrate the impact of social prescribing on their health and wellbeing. - Encourage individuals, their families, and carers to provide feedback and to share their personal stories about the impact of social prescribing on their lives.
- Work closely within the multi-disciplinary team to ensure relevant data is captured efficiently throughout the process and relevant reports are completed and reviewed - Work as part of the healthcare team to seek feedback and continually improve the service and contribute to business planning Professional Development - Work with Clinical Director and line manager to undertake continual personal and professional development, taking an active part in reviewing and developing the roles and responsibilities - Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.