Key responsibilities Take referrals from and make referrals to a wide range of agencies within Primary Care Networks. Co-produce personalised support plans with individuals, their families and carers to take control of their wellbeing, live independently and improve their health outcomes. Developing trusting relationships by giving people time and focus on what matters to me. Take a holistic approach, based on the persons priorities and the wider determinants of health. 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 needs is beyond the scope of the link worker role e.g. when there is a mental health need requiring a qualified practitioner. Key Tasks Referrals Be proactive in developing strong links with all local agencies to encourage referrals, recognising what they need to be confident in the service to make appropriate referrals. Work in partnership with all local agencies to raise awareness of social prescribing and how partnership working can reduce pressure on statutory services, improve health outcomes and enable a holistic approach to care. Work with the practice and community staff, to identify and support individuals at risk of loss of independence or hospital admission as a result of inadequate social support. Seek regular feedback about the quality of service and impact of social prescribing on referral agencies. Be proactive in encouraging self-referrals and connecting with all local communities, particularly those communities that statutory agencies may find hard to reach. Provide personalised support Meet people on a one-to-one basis, making home visits where appropriate within organisations policies and procedures. Give people time to tell their stories and focus on what matters to me. Help people identify the wider issues that impact on their health and wellbeing, such as debt, poor housing, being unemployed, loneliness and caring responsibilities. Develop a comprehensive knowledge of wider support services for people with non-clinical needs that impact on their wellbeing and health outcomes, such as social isolation, wellbeing, housing, unemployment, welfare benefits. Help people maintain or regain independence through living skills, adaptations, enablement approaches and simple safeguards. Work with individuals to co-produce a simple personalised support plan based on the persons priorities, interests, values and motivations including what they can expect from the groups, activities and services they are being connected to and what the person can do for themselves to improve their health and wellbeing. 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. The post holder will be required to have awareness and training in relation to relevant safeguarding policies and procedures and to raise any concerns regarding safeguarding on the individual to the attention of the relevant nominated lead within the team. Support community groups and VCSE organisations to receive referrals Forge strong links with local VCSE organisations, community and neighbourhood level groups, utilising their networks and building on whats already available to create a map or menu of community groups and assets. Develop supportive relationships with local VCSE organisations, community groups and statutory services, to make timely, appropriate and supported referrals for the person being introduced. Work collectively with all local partners to ensure community groups are strong and sustainable Work with GPs, PCNs and wider Multi-Disciplinary teams as required. Work with commissioners and local partners to identify unmet needs within the community and gaps in community provision and support development of new groups and services where needed. Encourage people who have been connected to community support through social prescribing to volunteer and give their time freely to others, in order to build their skills and confidence, and strengthen community resilience. General tasks 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. Work closely with GP practices within the PCN to ensure that they are receiving appropriate feedback about the people they have referred. Manage own workload through planning and organising own work schedule, obtaining and organising the necessary information and resources.