About this role
Job summary
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.
The role involves meeting patients and carers in a variety of settings, including GP practices, patients homes, and community venues. You will assess needs, support care planning, and help individuals access appropriate health, social care, and voluntary sector services. A strong understanding of local services is essential in order to effectively connect patients with the support available and help them overcome any barriers they may face.
Main duties of the job
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
Work collaboratively with other Social Prescribers and Link Workers Participate in training, education, and professional development activities Build strong working relationships with GPs and practice staff Work in accordance with practice policies and procedures Contribute to the wider aims of the Primary Care Maintain a flexible approach and undertake other reasonable duties as required
About us
Hedena Health is a GP partnership providing high-quality primary care services to patients across Oxfordshire. We are committed to delivering accessible, patient-centred healthcare through our team of GPs, nurses, healthcare professionals, and support staff. Our focus is on promoting health and wellbeing, delivering excellent patient care, and continuously improving the services we provide to our local communities.
A supportive and welcoming team environment. Opportunities to develop your skills and gain experience across a wide range of clinical and administrative functions. The opportunity to make a real difference to patients' health and wellbeing. A varied role where no two days are the same.
Job description Job responsibilities
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
Person Specification
Qualifications Essential
- Good standard of general education - GCSE English and Maths Grade C or equivalent - Strong IT skills, including email, Word and Excel - Full UK driving licence and access to a vehicle insured for work
Desirable
- Experience using EMIS clinical systems - Up-to-date knowledge of local services supporting patients and carers
UK Registration
Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).
Employer details Employer name Hedena Health Ltd
Address 207 London Road
Headington
Oxford
OX3 9JA
United Kingdom
Employer's website https://www.hedenahealth.co.uk (Opens in a new tab)