This role is part of ambitious plans for transforming care and ensuring timely and appropriate discharge arrangements. The post holder will be expected to operate flexibly and collaboratively with all stakeholders, demonstrating practical skills and excellent communication and                  co-ordination.  The role will be part of a multi-disciplinary team and will be central to the delivery of supported hospital discharge and post-acute care.  

The post will be employed by Uttlesford Community Action Network (UCAN), which is working in partnership with the health and social care system to deliver high quality patient care.  This role is critical to supporting the systems ambition to optimise hospital discharges and to support effective post-acute care. 

The focus of the role will be to support patients admitted to hospital, making decisions for themselves rather than being more dependent upon others. The post holder will be asking ‘What do you need help with?’ and seeking to find solutions that help maintain independence. By having knowledge of community and voluntary support groups and focusing on ‘what matters to me’ the post holder will take a holistic approach, connecting people to community groups and statutory services for practical and emotional support. 

The aim of the role will be to help to strengthen personal resilience, to reduce health inequalities by addressing the wider determinants of health and wellbeing and to provide practical support to achieve a safe and timely discharge from hospital. 

The post holder will work with all patient groups, but particularly with patients that are vulnerable and those with complex care needs which affect their ability to maintain independence.

• Promote social prescribing and its role in supporting self-management, within the context of facilitating timely hospital discharge.
• Actively promote and support the concept of ‘Ticket Home’ helping patients and their families to co-ordinate discharge and to support their post-acute care.
• Build relationships with key staff in the hospital, particularly ward staff and the complex hospital discharge team.
• Act as a conduit between the hospital and voluntary services, actively supporting the co-ordination of tasks to facilitate independent living and timely discharge.
• Monitor referrals for voluntary support, working and communicating effectively with locality community hubs and PCN Social Prescribing Link Workers.
• 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 enabling a holistic approach to care.
• Seek regular feedback about the quality of services and the impact of acute social prescribing on supporting timely discharge – our primary aim is to co-ordinate voluntary support to optimise patient self-management and to facilitate timely discharge to hospital capacity.

Provide personalised support

• Give people time to tell their stories and focus on ‘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 person’s assets.
• Be a friendly source of information about voluntary support networks and approaches.
• Help people identify the wider issues that will impact on the patient’s ability to manage their own care, following discharge from hospital.  This will inevitably focus on practical issues such as shopping, medicines collection, social contact and informal care support (outside of statutory care provision) 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 and the voluntary sector to support post-acute care.
• Help people maintain or regain their independence through living skills, adaptations, enablement approaches and simple safeguards.
• Work with individuals to co-produce a simple personalised support plan – based on the person’s 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, facilitate the introduction of people to community groups, activities and statutory services. 
• Where people may be eligible for a personal health budget and/or direct payment support, help them to explore this option as a way of providing funded, personalised support.
• Develop a team of volunteers to provide ‘buddying support’ for people leaving hospital.
• Co-ordinate post discharge calls for a period of up to six weeks post discharge, monitoring patient wellbeing and escalating any concerns to the appropriate statutory and voluntary providers. 

General tasks, including data capture

• Work sensitively with people, their families and carers to capture key information, enabling tracking of the impact of social prescribing on their discharge plan.
• Encourage people, their families and carers to provide feedback and to share their stories about the impact of social prescribing in supporting timely, facilitated hospital discharge and post-acute care needs.
• Support referral agencies to provide appropriate information about the person they are referring. Use the case management system to track the person’s 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 SystmOne and that the person’s use of the NHS can be tracked, adhering to data protection legislation and data sharing agreements.

Professional development

• Work with your line manager to undertake continual personal and professional development, taking an active part in reviewing and developing the roles and responsibilities.
• Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety.
• Work with your line manager to access regular ‘clinical supervision’, to enable you to deal effectively with the difficult issues that people present.

Miscellaneous

• Work as part of the team to seek feedback, continually improve the service and contribute to business planning.
• Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner.

• Duties may vary from time to time, without changing the general character of the post or the level of responsibility.

The post holder will take all reasonable care not to endanger themselves or anybody else by any act or omission as stated by the Health and Safety at Work Act 1974.

The post-holder must comply at all times with the Health and Safety policies, in particular by following agreed safe working procedures and reporting incidents using the organisations and practices Incident Reporting System. 

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. 

Special Working Conditions 

The post-holder is required to travel independently between practice sites (where applicable), and to attend meetings etc. hosted by other agencies. 

Confidentiality

The post holder must at all times maintain complete confidentiality of the material and information that they handle. Any matters of a confidential nature, or in particular, information relating to diagnosis and treatment of patients and individual staff records must, under no circumstances be divulged or passed onto any unauthorised person or persons.  The post holder must respect patient named confidentiality in keeping with ‘Caldicott principles’.  

Data Protection

The post holder is required to ensure that any personal information obtained, processed or held (on a computer or otherwise), is done so in a fair and lawful way and that the data held and processed is only for the specified registered purposes, in particular personal data relating to patients.  

Business Conduct, Governance and Standards

UCAN aim to maintain the goodwill and confidence of its own staff and of the general public. To assist in achieving this objective it is essential that, at all times, the post holder carries out their duties in a courteous, sympathetic manner. 

The post holder is required to comply with all policies and procedures in force and ensuring that the reporting requirements, systems and duties of action put into place by UCAN are complied with.

In upholding the good governance and standards, UCAN has an operations framework, which the post holder is expected to comply with and failure in this regard may lead to disciplinary action.  

Equal Opportunities

The Company has an Equal Opportunities Policy. The aim is to ensure that no individual receives less favourable treatment on the grounds of disability, age, sex, sexual orientation, marital status, race, colour, creed, ethic/national origin. Whilst the Company recognises specific responsibilities fall upon Management, it is also the duty of all employees to accept personal responsibility for the practical application of the Policy.

Training & Development

The successful post holder will be expected to be responsible for his/her continuing professional development and to take a proactive approach to maintaining personal and professional effectiveness in an evolving role.

Rehabilitation of Offenders Act

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.  

This job description is not a definite or exhaustive list of responsibilities but identifies the key responsibilities and tasks of the post holder. The specific objectives of the post holder will be subject to review as part of the individual performance review process.