Working in partnership with key staff in the GP practice to deliver their priorities, attending relevant meetings, and becoming part of the wider PCN team, giving information and feedback on social prescribing. As a member of the Personalised Care team, you will attend regular team meetings to give feedback on the service, raise issues, and receive briefings and updates from team members.
Accept referrals for people with health conditions (including common mental health conditions, obesity, diabetes, respiratory conditions, mobility issues, and sensory impairment) who wish to benefit from community support, focusing on people who are isolated. This includes self-referrals and online enquiries.
1. Proactively contact, engage and inspire people to take part, assessing their needs and offering a personalised approach to include face-to-face meetings, home visits, and telephone support as required.
2. Motivate, empower and encourage people to take positive action to improve their health and wellbeing, by connecting with others, attending groups, promoting self-care, volunteering, accessing advice, and information and support services. Set goals and develop plans with people to help them take control of their health and wellbeing.
3. Work with people in a supportive, holistic way (using a Motivational Interview approach) to address practical and psychological barriers, such as lack of transport, low confidence, and social isolation, to co-produce a solution.
4. Using the JOY system and directory, support people to choose appropriate community activities to support their well-being, such as exercise groups, self-help groups, debt advice, and community gardening.
5. Maintain regular, supportive contact to address issues as they arise and ensure people progress and achieve their goals.
6. Ensure all necessary data and information about patients, users, and volunteers is recorded accurately and confidentially on the practice database with awareness of information governance best practice.
7. Use recognised tools with patients to track improvements in their health and wellbeing, and work with the GP practice to review data on GP appointments and hospital admissions to track statistical improvements at practices.
8. Engage with Patient Participation Groups, existing community groups, patients, and staff to promote volunteer opportunities.
9. Work closely with the Personalised Care team to benefit from the co-ordination of activities and link in with the wider service offer.
10. Help to identify opportunities and activities in the local area which people could benefit from, such as local community groups, make contact, engage them in the service, and register them on the JOY directory (with support from colleagues).
11. Achieve targets for numbers of people engaged and supported and produce monthly monitoring reports as required.
#J-18808-Ljbffr