Primary Care Network (PCN) Staff

Management

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Social Prescriber

Social prescribing can help to strengthen community resilience and personal resilience, and reduces health inequalities, addressing the wider determinants of health by increasing patients’ active involvement with their local communities.

It particularly works for patients who: have long-term conditions (including support for mental health), are lonely or isolated, or have complex social needs which affect their wellbeing.

The role includes:

• Working with patients to co-produce a simple personalised support plan to address the patients’ health and wellbeing needs based on the person’s priorities, interests, values and motivations.
• Developing effective and supportive working relationships with local VCSE organisations, community groups and statutory services, to make timely, appropriate and supported referrals for patients.
• Working in partnership with local voluntary and community organisations to build a comprehensive directory of local resource to design and support social prescribing.
• Identifying local community assets and gaps in local provision.

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Care Coordinators

Care Coordinators are here to support groups of our population who may need additional or focused support generally due to health or social issues. This can include a wider range of things. Below is a summary of our Care Coordinators and who they are supporting.

Care Coordinators do a wider variety of tasks to support their group of patients but these include:

• utilise population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care;
• support patients to utilise decision aids in preparation for a shared decision-making conversation;
• help people 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, using tools to understand peoples level of knowledge, confidence in skills in managing their own health;
• support people to take up training and employment, and to access appropriate benefits where eligible for example, through referral to social prescribing link workers;
• assist people to access self-management education courses, peer support or interventions that support them to take more control of their health and wellbeing;
• provide coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals; and
• support the coordination and delivery of MDTs within the PCN.