Community Flow Key Worker

3 weeks ago

Barnstaple, United Kingdom Encompass Southwest Full time

**Responsible to**:OND Community Flow Manager and Nicola Topham, OND Flow Project Manager

**Context**

NDHT is part of One Northern Devon - a partnership of public, private, voluntary and community sector bodies. During the Covid-19 lockdown, One Northern Devon worked closely with the seven ‘One Communities’ across North Devon and Torridge to mobilise and support volunteers in every community, providing assistance to vulnerable neighbours who were isolating. A cascade system was put into place that meant that requests for volunteers could be made at Northern Devon level, local authority level or at community level and the request would come to the ‘One Community’ Community Developers who co-ordinated the function locally.

NDHT built on this success and created a ‘Home from Hospital’ volunteer service that utilises the One Community infrastructure, linking closely with the One Community Developers to enable a ‘Community around the Person’ approach, that connects patients with their local community, through the development of a Settle and Support at Home Service.

One Northern Devon’s Community Flow programme aims to provide better access to community support. It aims to ensure closer links between the hospital and the wider support available in communities from volunteers, the wider VCSE sector and the wider ‘One Community’ partnerships in the six towns and one village in Northern Devon.

The Community Flow Key Worker will manage the referral caseload from the OND ‘Community Flow’ programme, including interaction with other OND flow coordinators and the Settle at Home & Support at Home hospital discharge and admission avoidance service.

Referrals into the Settle at Home service will come via NDHT staff, whereas referrals into the Support at Home service will come from all parts of the health and social care system, which may include primary care, district nurse, the ambulance service, and a forward-thinking GP/Practice Nurse who knows their patient is going into/is in hospital and have no support networks.

Both services involve an assessment of the needs of the patient and a decision as to whether a volunteer visit would be beneficial, or connection into another offer from the third sector or other provider.

The Community Flow Key Worker will ensure that all referrals are managed in a timely and professional manner, placing the patient at the centre of the intervention. Close liaison with the in-hospital volunteering service and Community Developers across Northern Devon will be required.

**Why is Community Flow needed?**

People most in need of support are least likely to receive it. They are expected to fit in with what services need rather than the other way around and many describe feeling that no-one cares. They feel ‘bounced around’ services and telling their story again and again, which can be distressing, particularly for people who have experienced trauma. People feel distanced from the professionals that support them as they get referred to various providers for more specialised support.

What if people told their story once - they were listened to and understood and community support was drawn in to ‘flow’ around them?

**What is our ‘Community Flow’ approach?**

Flow is a way of helping people get the full support they need to live the life they want.

Rather than referring people to various practitioners for non-medical support, a trusted person is identified to have a ‘What Matters’ conversations with the person themselves. These conversations focus on the person’s goals and strengths as well as their needs and a plan is developed together, facilitated by the community flow key worker. The trusted person ‘pulls in’ the support needed with the help of the Community flow key worker so that support ‘flows’ around the person rather than the person bouncing around the system.

Funding for this role is from the NHS Charities Together and has the Community Flow programme has the following outcomes:
**Outcome 1**

A comprehensive programme of support, accessible to all health & social care staff to refer patients into

**Outcome 2**

More resilient communities who have the support and structure to make best use of all the available assets in their community

**Settle and Support at Home Service**

**Key Working Relationships**:

- NDHT Discharge Co-ordinators
- NDHT Short term services members
- NDHT Daily Forum members
- OND Community Flow Manager
- OND Flow manager
- One Communities Support Manager
- One Community Developers
- Primary Care Network Social prescribers and Community Connectors
- One Community Chairs
- One Northern Devon Flow Team
- Settle and Support at Home Volunteers

**Other working relationships**

The post holder is required to deal effectively with staff of all levels throughout the Trust, the wider healthcare community, external organisations, volunteers, VCSE groups and the public. This will include verbal, written and el

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