Social Prescribing Link Worker

**The key duties of the social prescribing link worker are**: Key responsibilities The Link worker will work closely together with a senior link worker, the PCN Clinical Directors and Overseeing Group. The responsibilities outlined below will be further defined when further national guidance is available and with input from PCN Clinical Directors, local partners and patients. Key responsibilities of this role are to: 3.1 Deliver personalised 1:1 support Provide personalised support to patients with complex needs: the nature of patient needs will vary but may include frailty, carers, long term conditions, mental health and social issues Take a holistic approach, based on the service users priorities and the wider determinants of health to make a personalised support plan together in order to improve health and wellbeing. Manage and prioritise a network caseload (caseload number to be determined) working with the network team, in accordance with the needs, priorities and any urgent support required by individuals on the caseload.

Working with PCN to develop a system of managing a caseload, to enable a sufficient level of intervention with a practical caseload of service users. Ensure care and support received within the neighbourhood is recorded and shared (with patient consent) with all appropriate health and care providers. Introduce or reconnect people to community groups and statutory services, for longer term provision of support, as required. Key Tasks Include: Making contact with people on a one-to-one basis; giving people time to tell their stories and focus on what matters to me, developing/inputting into a personalised support plan together.

Making home visits (when possible), where appropriate, within organisations policies and procedures. 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. Help service users maintain or regain independence through living skills, adaptations, enablement approaches 3.2 Build relationships with Voluntary Community Sector (VCS) organisations and community groups supporting our local model of social prescribing Draw on the strengths and capacities of our local communities, enabling local VCS organisations and community groups to receive social prescribing referrals. Work with the VCS to ensure the basic safeguarding processes for vulnerable individuals are in place and can provide opportunities for the service user to develop friendships, a sense of belonging, and to build knowledge, skills and confidence. Work with local partners to support local VCS organisations and ensure that community assets are nurtured.

For example, by making them aware of small grants, identifying and providing support to set up local events, community groups and services where gaps are identified in local provision. Key Tasks include: Forging strong links with local VCS organisations, community and neighbourhood level groups. Develop supportive relationships with local VCS organisations, community groups and statutory services, to make timely, appropriate and supported referrals for the service user being introduced. Ensure that local community groups and VCS organisations being referred to have basic procedures in place for ensuring that vulnerable individuals are safe and, where there are safeguarding concerns, work with all partners to deal appropriately with issues.

Work closely with GP practices within the PCN to ensure that social prescribing referral codes are inputted to EMIS and that the persons use of the NHS can be tracked, adhering to data protection legislation and data sharing agreements with the clinical commissioning group (CCG). 3.3 Set up, establish role, embed within and receive referrals from the Network/Neighbourhood Work with the PCN to design and develop a process and plan for the integration of the link worker role within General Practice and wider health and care system. This will include planning and setting up the Link Worker referral process. Establish connections and relationships with local health and care provider organisations to understand landscape, ethos, ways of working and how you will work with a multidisciplinary team.

Build an understanding of local processes, referral pathways and reporting mechanisms to understand how your role can support communication of patient progress and outcomes across systems/providers. Help colleagues in the PCN to develop the service. Share the learning that you gain from best practice, appropriate guidance and local exemplars. Key Tasks Include: Building relationships w