Key Tasks and Responsibilities 1. To provide holistic one-to-one-person centred support for people aged 18 and over who have high dependency on emergency services and who are frequent visitors/ callers of A&E, the Urgent Care Centre, and East Midlands Ambulance Service. Carry out the role of a facilitator, broker, sign poster, community connector, and navigator, acting as an enabler between the voluntary and community sector, patients, GPs ,health clinicians, and social care. Provide support to patients, generally in their own homes, up to 3-4 months to help direct and connect them to alternative sources of non-medical support services and activities.
Offer a personalised approach to sensitively uncover the real reasons for them calling 999 or presenting frequently at A&E/UCC. During client visits undertake an assessment to gather baseline data and to identify the support needs and actions. Generating personalised care and support or wellbeing plans, which may include risk management. Ensure support actions agreed with the patient are carried out by the service.
Support areas could include making referrals into a range of services provided by the voluntary, statutory or private sector, help with non-means tested benefit form filling e.g. Personal Independent Payments, Attendance Allowance, housing forms etc, distributing food bank vouchers, identifying suitable volunteering opportunities, connecting people into peer to peer led activities, initially taking patients to services if their confidence is low etc. Once support has been provided carry out a final assessment 2. To meet and collaborate with A&E clinical staff regularly, to discuss, identify and agree appropriate referrals from the patient cohort list (patients presenting more than 12 times per year) and other patients presenting less than 12 times per year at A&E.
Meet with a range of health clinicians to discuss and agree appropriate referrals from the patient cohort list. Build and maintain positive relationships with a range of health professionals. Work closely with health clinicians to facilitate optimal joint working on safe and effective care for patients with complex needs. Raise awareness of voluntary and community sector activities and services on offer to showcase the diverse range of services available to health and social care practitioners.
Raise awareness of the social prescribing service with health practitioners. With health professionals and a range of providers identify service needs, broker solutions and when required enable individuals to be supported to kick start/lead on new activities through Lincolnshire CVS. 3. To work and collaborate with the voluntary and community sector to help identify appropriate referral destinations and to explore opportunities to meet gaps in services and activities.
Keep abreast of a wide range of support services on offer in the voluntary and community sector through undertaking research, making connections with organisations and groups and by using a range of local online directories and Community Connectors. Build and maintain positive relationships with a wide range of voluntary and community sector providers. When gaps in services and activities are identified discuss and raise these with the team and if required, liaise with voluntary organisations and Community Connector to help identify solutions. 4.
To ensure effective record keeping and storage of patient data to demonstrate outputs and outcomes which is compliant with GDPR. Ensure all patient records and actions are entered onto our record keeping systems. Ensure GDPR requirements are adhered to in relation to data management. When required, support in gathering any data required for working out cost savings to the wider health and social care sector as a result of the service interventions.
1. To actively contribute as a member of a well-established social prescribing and Neighbourhood team who support the most vulnerable in society. Actively contribute to team meetings, away days, planning activities and reflective practice activities. Share progress, learning and challenges within the existing Integrated Plus social prescribing team.
Share ideas about how the service could develop and evolve. Adhere to all Meridian Medical PCN policies and procedures e.g. lone working, patient consent, information governance, and local governance policy and procedure etc.