Primary Duties and Areas of Responsibility Take referrals from multiple agencies Provide personalised support to individuals, their families and carers to take control of their wellbeing, live independently and improve their health outcomes. Develop trusting relationships by giving people time and focus on what matters to them. Take a holistic approach, based on the persons priorities and the wider determinants of health. Co-produce a personalised support plan to improve health and wellbeing, introducing or reconnecting people to community groups and statutory services. The role will require managing and prioritising a caseload, in accordance with the needs, priorities and any urgent support required by individuals. It is vital that the post holder has a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when the persons needs are beyond the scope of the link worker role e.g. when there is a mental health need requiring a qualified practitioner. 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. Draw on and increase the strengths and capacities of local communities, enabling local VCSE organisations and community groups to receive social prescribing referrals. Ensure they are supported, have basic safeguarding processes for vulnerable individuals and can provide opportunities for the person to develop friendships, a sense of belonging, and build knowledge, skills and confidence. Promote social prescribing, its role in self-management, and the wider determinants of health. Build relationships with key staff in GP practices within the local Primary Care Network (PCN), attending relevant meetings, becoming part of the wider network team, giving information and feedback on social prescribing. Provide referral agencies with regular updates about social prescribing, including training for their staff and how to access information to encourage appropriate referrals. 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 their view what matters to me. Build trust with the person, providing non-judgmental support, respecting diversity and lifestyle choices. Work from a strength-based approach focusing on a persons assets. Be a friendly source of information about wellbeing and prevention approaches. 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. 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. Where people may be eligible for a personal health budget, help them to explore this option as a way of providing funded, personalised support to be independent, including helping people to gain skills for meaningful employment, where appropriate. 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. Use these opportunities to promote micro-commissioning or small grants if available. Develop supportive relationships with local VCSE organisations, community groups and statutory services, to make timely, appropriate and supported referrals for the person being introduced. Ensure that local community groups and VCSE 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. Where such policies and procedures are not in place, support groups to work towards this standard before referrals are made to them. Check that community groups and VCSE organisations meet in insured premises and that health and safety requirements are in place. Where such policies and procedures are not in place, support groups to work towards this standard before referrals are made to them. Support local groups to act in accordance with information governance policies and procedures, ensuring compliance with the Data Protection Act. Communication: The post-holder should recognise the importance of effective communication within the team and will strive to: Communicate effectively with other team members, attend Practice meetings and contribute as necessary. Communicate effectively with patients and carers Recognise peoples needs for alternative methods of communication and respond accordingly Confidentiality In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately. The post-holder should always respect patient confidentiality and not divulge patient information unless sanctioned by the requirements of the role. Information Technology 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 into EMIS and that the persons use of the NHS can be tracked. Also that the PCN documentation and other important documentation is maintained on the Document Management System (GP Clarity) adhering to data protection legislation and data sharing agreements with the Integrated Care Board (ICB). Work closely with the NHS Central Support Unit (CSU) and the Practice Managers to manage data collection, record appropriate coding, analyse reports etc to enable informed decision making and continuous quality improvement. Continuous Professional Development The post-holder will undertake regular professional development as agreed for the role, taking an active part in reviewing and developing the role and responsibilities and provide evidence of learning activity as required e.g. personalised care planning. Equality and Diversity The post-holder must co-operate with all policies and procedures designed to ensure equality of employment. Co-workers, patients and visitors must be treated equally irrespective of gender, ethnic origin, age, disability, sexual orientation, religion etc. The post holder will contribute to tackling inequalities in health and social care particularly regarding individuals with long-term conditions. An ethos of promotion of independence and partnership-working is integral to this post. Miscellaneous Demonstrate a flexible attitude and be prepared to carry out other duties as may reasonably be required within the general character of the post, ensuring that work is delivered in a timely and effective manner. Other duties which may be decided upon by the Kirkham and Wesham PCN Board from time to time Work in accordance with the PCNs policies and procedures. Contribute to the wider aims and objectives of the PCN to improve and support primary care. Job Description Agreement This Job Description is flexible and the post holder will be expected to undertake any other duties appropriate to the role and grade as may be required by the GPs/Practice and PCN Management. This job description is subject to change from time to time in line with organisational need and the post holders agreement should not unreasonably be denied