PCN Social Prescribing Link Worker

Main duties of the job

Please see attached job description for further information about the main duties of the Social Prescribing Link Worker role.

The Health Triangle PCN is a PCN has 3 practices looking after approximately 52,000 patients across Bracknell, Crowthorne, Owlsmoor and Sandhurst. We have a large team of GPs, allied health professionals, nurses and administrative staff.

We are a training practice as well with student GPs, Paramedics, Physician Associates, Clinical Pharmacists and Nurses.

Summary of main job purpose:

Working under direct supervision of a GP Lead provide social prescribing that empowers people to take control of their health and wellbeing and shift the focus back to what matters to them. Taking a holistic approach to an individuals health and wellbeing, connecting people to community groups and statutory services for practical and emotional support. You will also support existing groups to be accessible and sustainable and work collaboratively with all local partners.

You will work as a key part of the Primary Care Network (PCN) multi-disciplinary team, helping PCNs to strengthen community and personal resilience and reducing health and wellbeing inequalities by addressing the wider determinants of health, such as debt, poor housing and physical inactivity, by increasing people's active involvement with their local communities.

• 1.Take referrals from the PCNs GP practices and multi‑disciplinary teams in 2019/20. From 2020/21 this referral pathway will increase to take referrals from local agencies including pharmacies, wide 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. Self‑referral is also encouraged.
• 2.As a key member of the PCN multi-disciplinary team, you will provide personalized support to individuals, their families and carers to take control of their health and wellbeing, live independently and improve their health outcomes. You will 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.
• 3.Co‑produce a simple personalized care and support plan to improve health and wellbeing, introducing or reconnecting people to community groups and statutory services.
• 4.Meet people on a one‑to‑one basis, making home visits where appropriate within organisations policies and procedures.
• 5.Managing and prioritising your own caseload, in accordance with the needs, priorities and any urgent support required by individuals. It is vital that you have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person's needs are beyond the scope of the link worker role – e.g. when there is a mental health need requiring a qualified practitioner.
• 6.Working closely with the voluntary and community sector, draw on and help to increase the strengths and capacities of local communities, enabling local VCSE organisations and community groups to receive social prescribing referrals.
• 7.Alongside other members of the PCN multi‑disciplinary team, work towards supporting the local VCSE organisations and community groups to become sustainable.
• 8.Work with commissioners and local partners to identify unmet needs within the community and gaps in community provision.
• 9.Represent the PCN and CNC professionally at all times.
• 10.Ensure that community assets are nurtured, through sharing intelligence regarding any gaps or problems identified in local provision.
• 11.Champion Social Prescribing and support educating non‑clinical and clinical staff within their PCN multi‑disciplinary teams on what other services are available within the community and how and when patients can access them. This may include verbal or written advice and guidance.
• 12.Build positive relationships that promote a two‑way referral process with statutory services, other providers, charities and groups; identify gaps…