Community Link Worker

3 weeks ago

Hertford, United Kingdom Hospital and Community Navigation Service Full time

At the request of Hertfordshire County Council, seven voluntary organisations have formed a partnership to develop a new service bringing together Hertfordshire’s current Community Navigation and Hospital Discharge Services.

The vision is to create a Herts-wide Integrated Hospital Discharge and Community Navigation Service (IHDCNS), with teams based locally that will understand their local populations, and support people over the age of 18 who are returning home from hospital or are in need of additional support due to ill health. Helping to find, navigate and access community-based support.

Delivering within a new, innovative social prescribing model, the outcomes of this new service are as follows:
1. Reducing hospital admissions;
2. Reducing GP visits;
3. Reducing reliance on home care providers;
4. Reducing social isolation;
5. Improving health and wellbeing.

**Main purpose of the post**:

- Provide the delivery of the new Home and Hospital Navigation Service
- Support the partnership and the voluntary and community sector and other local partners to deliver of an effective and integrated service which helps people access the support they need in their own communities.
- Work as full member of the new locality team, supporting people who are perceived to have some kind of risk (for example isolation, not understanding or managing their condition or situation) and making sure they have any advice and help needed to access appropriate support.
- Work as a full member of the team to support people being discharged from Hospital and reduce the likelihood of readmission by helping them to regain and retain independent living. As well as finding and accessing further support.
- Deliver the service alongside a network of volunteers and local providers across Hertfordshire.
- Activate and link existing resources in the community to meet the needs of the service user; where this is not possible highlight areas of unmet need.
- Target groups/communities which are evidenced as having worse health and wellbeing outcomes and being less able to use advice which will improve their health to make use of services

**Principal responsibilities**

1. **Service Delivery**
- Work with health, mental health and social care professionals as part of an integrated discharge process for older and/or vulnerable people leaving hospital and A&E/ Urgent Care departments to assist service users and carers to settle back in at home.
- Work with community based health and social care providers such as GP surgeries, HomeFirst teams and adult care services to assist individuals who are in need of additional help, support and guidance (outside of statutory services) to ensure problems and issues do not worsen and lead to ‘crisis’.
- Contact prospective service users, either in hospital, immediately after discharge or within the community to ascertain their needs and preferences, via a service user assessment, using appropriate guidance and paperwork and training.
- Ensure that clients and service users develop sustainable relationships with organisations and services that can help service users to live well and avoid crisis.
- Provide emotional and practical support and advice where needed following a service user assessment.
- This may include the following:

- Provide transport to service user’s home by car on discharge from hospital wards, A&E departments & community hospitals.
- Carry out essential shopping or collecting prescriptions.
- Provide on-going assessment and support planning for service users’ needs, to provide appropriate support and achieve positive outcomes.
- Carry out follow-up welfare checks and visits as required and assist service users with their activities to re-enable their daily living skills (within a set time criteria).
- Assess the service users living environment through carrying out a risk assessment and providing information/advice whilst respecting their individual dignity, choice and rights.
- Provide support and information to clients and service users so that they can build sustainable relationships with, groups and activities which help build resilience and independence.
- Record and report activities undertaken and highlight any changes in a service user’s condition or circumstance and ensure that appropriate actions are taken to support the person.
- Liaise with social care, health, housing and other professionals to ensure that the needs of the individual are consistently met.
- Support brokers and individuals to spend direct payments/personal budgets/own resources where this is appropriate on services people want from the community.
- Become the ‘go to’ person for both statutory and voluntary sectors when no obvious solution for a particular individual can be identified

1. **Quality and performance**
- Deliver great outcomes for individuals and the service and is accountable.
- To make clear, goal-oriented ‘plans’ with service users to support short, medium and longer term

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