Social Prescribing Lead Link Worker

The Role: The Team Lead for Social Prescribing & Link Workers is responsible for the delivery of a professional, efficient and effective co-ordination service through effective management of the team of Social Prescribers and Link Workers. They will line manage, coach and support the team to meet their set objectives and KPIs as well as providing effective support and the best possible care for patients. The post holder will engage with the leadership of other providers supporting the PCNs patients to deliver collaborative solutions that improve patient outcomes and sustainability of PCN / GP services. Alongside managing the team, the team lead will also be a Social Prescriber Link Worker that will hold his/her own caseload of patients. Social prescribing empowers people to take control of their health and wellbeing through referral to non-medical Link Workers who give time, focus on what matters to me and take a holistic approach, connecting people to community groups and statutory services for practical and emotional support. Link workers support existing groups to be accessible, working collaboratively with all local partners. Social prescribing can help to strengthen community resilience and personal resilience and reduces health inequalities by addressing the wider determinants of health, such as debt, poor housing and physical inactivity, by increasing peoples active involvement with their local communities. It particularly works for people with long-term conditions, for people who are lonely or isolated, in debt, unemployed, have poor or no housing or have complex social needs which affect their wellbeing. Key duties and responsibilities Line management of a Team of social prescribers. Manage the overall caseload of patients for the PCN. Audit social prescriber teams caseload, providing feedback, coaching and guidance to the social prescriber. Proactively identify and work with vulnerable patients to support their personalised care requirements, using the available decision support aids. Holistically bring together all of a persons identified care and support needs and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person. Help patients, carers, and family members to manage their needs through answering queries, making, and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care. Engage with and act as contact point on behalf of the PCN with other service providers (including health, social, voluntary sector) who support vulnerable patients. Provide coordination and delivery of Multi-Disciplinary Team meetings for vulnerable patients within the PCN. Including, but not limited to the raising of complex cases or concerns to the MDT. Proactively find resolutions or escalate issues, concern and monitoring regarding a vulnerable patient Liaising with all internal teams to support a vulnerable patients needs. Provide signposting support to patients, carers, and family members on information about a patient condition(s). Explore and assist people to access personal health budgets where appropriate. Provide coordination and navigation for people and their carers across health and care services, alongside working closely with Social PrescribingLink Workers and other care coordinators. Provide support and training to patients, carers and family members to make the best use of the PCNs IT systems e.g. for requests, prescriptions, consultations etc. Utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care. Support patients, carers and their family members to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and wellbeing, including through the use of the Patient Activation Measure - https://www.england.nhs.uk/personalisedcare/supported-self-management/patientactivation/ Assist patients, carers and their family members to access self-management education courses, peer support or interventions that support them in their health and wellbeing and increase their activation level. Liaise with the GP Partner responsible for vulnerable patients to agree strategy, implementation and monitoring of outcomes Provide monitoring, oversight and reporting against set objectives and Key Performance Indicators to the Partners and wider LWP team. Proactively utilise protocols and guidance available to ensure patients, carers and family members are provided with accurate and up to date information. Develop a sound understanding of significant events and how to report them. Undertake and participate in any training required including mandatory updates/refresher training. Support the PCN in preparing for CQC or other external inspections or audits. Manage team to deliver PCN targets, improve patient outcomes, promote service achievements and work collaboratively with other providers. Responsible for the co-ordination and delivery of specific projects associated with the role. Take referrals from and work with GP practices and other professionals within the PCN as well as receiving self-referrals from the public.). Establish and maintain effective communication pathways with all practice staff and external teams appropriate to role. Proactively participate in learning and development activities and opportunities. Lead and engage with regular team meetings, 1:1s and appraisals; providing, listening, and responding to constructive performance feedback. Contribute to the effectiveness of the role by reflecting on own and team activities and making suggestions on ways to improve and enhance performance. Manage own time, workload and resources to ensure priorities are met and quality is not compromised. Promote and help to enhance the reputation of Living Well PCN in accordance with policies and procedures, promoting good relations with patients and other health care professionals through effective communication skills. Other duties The PCN services are constantly evolving and therefore changes in employees duties may be necessary from time to time. The post holder will be required to undertake other appropriate duties according to the needs of the service, requested by a manager. Travel The post holder may be required to travel to other practices within the Primary Care Network during their working day although this will be kept to a minimum where possible. It is a requirement of all staff that they are aware of and follow the PCNs policies and procedures, with attention to patient confidentiality, health and safety, infection. Control, equality and diversity and customer service excellence. To further your development and knowledge you will be expected to attend training as necessary. The PCN reserves the right to amend this role profile as necessary, after consultation with the post holder, to reflect changes in or to the job. Key results Measurable positive outcomes and feedback from patients, carers and family members Monthly publication of an achievements, stories and impacts to promote the service. Development and implementation of collaborative solutions with other providers across the Lewisham Borough and southeast London. Data capture Work sensitively with people, their families and carers to capture key information, enabling tracking of the impact of Social Prescribing on their health and wellbeing. Encourage people, their families, and carers to provide feedback and to share their stories about the impact of Social Prescribing on their lives. Support referral agencies to provide appropriate information about the person they are referring. Use the case management system to track the persons progress. Provide appropriate feedback to referral agencies about the people they referred. Work closely with GP practices within the PCN to ensure that Social Prescribing referral codes are inputted to EMIS/System One/Vision 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). Clinical Governance Identify risk issues that impact on peoples health or social care needs. Take appropriate action to the significance of the risk and consistent with protection procedures, applying protection procedures, following lone worker procedure. Demonstrate effective team working inclusive of all relevant professionals. Report all accidents / incidents, and all ill health, failings in equipment and / or environment to line managers. Contribute towards audit and data collection as required. Once assessed as competent will be accountable for their own practice within their area of responsibility when identified and agreed with the line manager. Professional development Work with your 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, and health and safety. Work with the Clinical Director to access regular clinical supervision, to enable you to deal effectively with the difficult issues that people present