About the role
Salary: Negotiable
You will work closely with GPs and practice teams to manage a caseload of identified patients, ensuring appropriate support is in place and that patients evolving needs are identified and addressed.
Accept referrals from GPs and multidisciplinary team members
Meet patients in community or home settings to review proactive care plans
Communicate care plans clearly to GPs and other professionals and update clinical records
Support access to community care and carers assessments where appropriate
Identify unpaid carers and link them to relevant support services
Provide basic benefits guidance and signpost to specialist advice where needed
Support patients with personal budgets, including advising on key choices
Keep GPs and practice teams informed of available community resources.
Support care delivery that promotes independence and prevents unnecessary admissions
Participate actively in MDT meetings
Identify when urgent action or escalation of care is required and raise concerns promptly
Maintain accurate, up-to-date records using GP clinical systems and other relevant IT systems
Contribute to reports, meetings, and presentations related to service development
Identify gaps in services and feedback improvement opportunities
Develop and maintain an in-depth knowledge of local community, statutory and voluntary sector services
Work with practice teams to identify patients at risk of loss of independence or hospital admission due to inadequate social support
Support GPs in reviewing, updating, and implementing personalised care plans for elderly, frail, or long-term condition patients
Provide time-limited, supported signposting to appropriate services (free or paid where relevant)
Ensure patients receive the right level of support at the right time through effective coordination with service providers
Promote joined-up care by acting as a key point of contact between patients, carers, GPs, Integrated Locality Teams (ILT), social services, and other agencies
Encourage effective help-seeking behaviours and help reduce avoidable hospital admissions and A&E attendances
Respond to communications from out-of-hours and inpatient services regarding changes in patient status
Maintain up-to-date records of hospital inpatients and support discharge coordination with ILT
Record referrals, interventions, and outcomes to support service monitoring and evaluation
Contribute to service development, risk assessments, and impact evaluations
Work collaboratively with commissioners, ILTs, and partner organisations to develop the Social Prescribing role