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About Us:

The Confederation, Hillingdon CIC works with general practice and other healthcare providers in Hillingdon to deliver high quality clinical services to patients. Our aim is to improve care for patients by working collaboratively across primary care and our partners as part of the Integrated Care Partnership. The Confederation team also work to develop and support individual GP practices, PCNs and Neighbourhoods and their changing needs. We are of the NHS but independent, innovative and transformational.

General capacity across primary care is being expanded rapidly. The Confederation is determined to develop as an attractive place to work that provides rewarding roles and opportunities to grow in order to attract and retain great staff that in turn provides the highest quality care.

Our Values:

Job Summary:

Health coaching is a partnership between health and care practitioners and people. It guides and prompts people to change their behaviour, so they can make healthcare choices based on what matters to them. It also supports them to become more active in their health and care. Helping people gain and use the knowledge skills and confidence to become active participants in their own care; to achieve self-identified health and wellbeing goals.

Health and wellbeing coaches predominately use health coaching skills to support people with lower levels of patient activation to develop the knowledge, skills, and confidence to manage their health and wellbeing, whilst increasing their ability to access and utilise community support offers. They may also provide access to self-management education, peer support, and social prescribing.

Health and wellbeing coaches will take an approach that considers the whole person in addressing existing issues and encourages proactive prevention of new and existing illnesses. Health coaches try to understand patients lives holistically, use personalised coaching techniques to build up their motivation to change, and then supporting them to realise their own goals. They will take an approach that is non-judgemental, based on strong communication and negotiation skills, that supports personal choice and positive risk taking that addresses potential consequences, and ensures patients understand the accountability of their own decisions.

Primary Responsibilities:

• Coach and motivate patients through multiple sessions to identify their needs, set goals, and support them to implement their personalised health and care plan.
• Provide personalised support to individuals, their families and carers to ensure that they are active participants in their own healthcare; empowering them to take more control in managing their own health and physical wellbeing, to live independently, and improve their health outcomes through joint care planning.
• Assist with signposting patient and carers to the appropriate health, mental and social care services within the community.
• Assist patients in building resilience within the community and make informed decisions and choices when their health changes.
• Help to identify gaps and develop resources for individuals, such as peer support groups and provide interventions such as self-management and education.
• Supporting people to establish and attain goals set by identifying what is important to them, documenting and producing a patient centred joint care plan.
• Using Digital platforms to support people to improve their health and wider wellbeing.
• Working with the social prescriber, care coordinator and other services to connect them to community-based activities which support their health and wellbeing.
• Contemporaneous recording the data on EMIS and use of templates and codes. Jointly creating personalised care plan with care coordinators, social prescriber and or other primary care staff in reviewing and meeting the personalised needs of the patients.
• Work with people with lower activation to understand their level of knowledge, skills and confidence (their Activation level) when engaging with their health and wellbeing.
• Assess, advise and encourage patients to jointly agree the action plan and ensure that it is achieved in timely fashion.
• Support people to manage their own health staying healthy, making informed choices of treatment, managing conditions and avoiding complications.
• Assist in achieving improved health outcomes when incorporating health coaching in the care of patients with a number of the most prevalent long-term conditions.
• Use conversational skills in their day to day work with patients.
• Building intensive and integrated approaches to empower people with more complex needs, including those living with multi-morbidity, to experience coordinated care and support that supports them to live well, helps reduce the risk of becoming frail, and minimises the burden of treatment.
• Provide support to local community groups and work with other health, social care and voluntary sector providers to support the patients health and well-being holistically.
• Ensure that fellow PCN staff members are made aware of health coaching and social prescribing services and support colleagues to improve their skills and understanding of personalised care, behavioural approaches, and ensuring consistency in the follow up of peoples goals where an MDT is involved.

Referrals:

• Promote health and wellbeing, its role in self-management, addressing health inequalities and the wider determinants of health.
• As part of the PCN multi-disciplinary team, build relationships with staff in GP practices within the local PCN, attending relevant MDT meetings, giving information and feedback on social prescribing.
• Be proactive in developing strong links with all local agencies to encourage referrals, recognising what they need to be confident in the service to make appropriate referrals.
• To work inclusively with the Primary Care Networks member practices, The Confederation, H4All and other members of the multi-disciplinary team.
• Work in partnership with all local agencies to raise awareness of health and wellbeing and how partnership working can reduce pressure on statutory services, improve health access and outcomes and enable a holistic approach to care.
• Provide referral agencies with regular updates about health and wellbeing, including training for their staff and how to access information to encourage appropriate referrals.
• Seek regular feedback about the quality of service and impact of social prescribing on referral agencies.
• Be proactive in encouraging equality and inclusion, through self-referrals and connecting with all diverse local communities, particularly those communities that statutory agencies may find hard to reach.

Provide personalised support:

• Meet people on a one-to-one basis, making home visits where appropriate within organisations policies and procedures. Give people time to tell their stories and focus on what matters to me. Build trust and respect with the person, providing non-judgemental and non-discriminatory support, respecting diversity and lifestyle choices. Work from a strength-based approach focusing on a persons assets.
• To undertake holistic client needs assessments in the surgery, using the Patient Activation Measure (PAM) assessment and the ONS4 Wellbeing questionnaire full training on their use will be provided.
• Be a friendly and engaging source of information about health, wellbeing and prevention approaches.
• Help people identify the wider issues that impact on their 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.
• Help people maintain or regain independence through living skills, adaptations, enablement approaches and simple safeguards.
• Work with individuals to co-produce a simple personalised support plan to address the persons health and wellbeing needs based on the persons priorities, interests, values, cultural and religious/faith needs 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.
• Act as the bridge between health and care workers and local communities in order to make more effective use of social capital. Where appropriate, physically introduce people to culturally appropriate community groups, activities and statutory services, ensuring they are comfortable, feel valued and respected. Follow up to ensure they are happy, able to engage, included and receiving good support.
• Where people may be eligible for a personal health budget, help them to explore this option as a way of providing funded, personalised support to be independent, including helping people to gain skills for meaningful employment, where appropriate.
• Seek advice and support from the GP supervisor and/or identified individual(s) to discuss patient-related concerns (e.g. abuse, domestic violence and support with mental health), referring the patient back to the GP or other suitable health professional if required. Support community groups and VCSE organisations to receive referrals.

Community Development:

• Forge strong links with a wide range of local VCSE organisations, community and neighbourhood level groups, utilising their networks and building on whats already available to create a menu of diverse community groups and assets, who promote diversity and inclusion.
• Develop supportive relationships with local diverse VCSE organisations, culturally appropriate community groups and statutory services, to make timely, appropriate and supported referrals for the person being introduced. Work collectively with all local partners to ensure community groups are strong and sustainable
• Work with commissioners and local partners to identify unmet diverse needs within the community and gaps in community provision. Map community resources and build and build community capacity to meet identified gaps in provision.
• Encourage people who have been connected to community support through social prescribing to volunteer and give their time freely to others, building their skills and confidence and strengthening community resilience.
• Encourage people, their families and carers to provide peer support and to do things together, such as setting up new community groups or volunteering.
• To ensure that the Link Worker programme is integrated into Hillingdons well-established social prescribing programme, delivered by H4All.

Measuring Effectiveness:

• Work sensitively with people, their families and carers to capture key information, enabling tracking of the impact of social prescribing on their health and wellbeing.
• Encourage people, their families and carers to provide feedback and to share their stories about the impact of social prescribing on their lives.
• Support referral agencies to provide appropriate information about the person they are referring. Provide appropriate feedback to referral agencies about the people they referred.
• Work closely within the MDT and with GP practices within the PCN to ensure that the social prescribing referral codes are inputted into clinical systems (as outlined in the Network Contract DES), 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 role and responsibilities.
• Involved in regular one to one meetings with line manager to discuss targets and outcomes achieved.
• Work with your line manager to access regular clinical supervision, to enable you to deal effectively with the difficult issues that people present.
• Review yearly progress and develop clear plans to achieve results within priorities set by others.
• Participate in the delivery of formal education programmes.

Service Development/ Training:

• Attending any relevant training organised by the PCN Manager/CD for continuous professional development.
• Be involved within clinical supervision sessions with peers and superiors.
• Contribute to the maintenance of a good clinical climate for learners and assist in the in-service training for fellows or trainee
• Train and assist where practical and reasonable with PCN DES, NSS [National Service Specification] and SNS [Supplementary Network Services] etc.

Health and Safety / Risk Management:

• The post-holder must comply at all times with all local Health and Safety policies, in particular by following agreed safe working procedures and reporting incidents using the organisations Incident Reporting System.
• The post-holder will comply with the Data Protection Act (1984) and the Access to Health Records Act (1990).
• 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.

Patient Confidentiality:

• The post holder must at all times respect patient confidentiality and, in particular, the confidentiality of electronically stored personal data in line with the requirements of the General Data Protection Regulation and in keeping with The Confederation, Hillingdon CIC Information Governance Policy and procedures.
• The post holder should not divulge patient information unless sanctioned by the line manager and required for the role.
• Communication & Working Relationships:
• The post-holder will establish and maintain effective communication pathways at all times with project team members.

Special Working Conditions:

• The post-holder is required to travel independently between sites (where applicable), and to attend meetings etc. hosted by other agencies. In addition to this, the role of the Social Prescriber does require visits to patients homes and other locations that would be linked to their needs i.e. attendance at Court.

Job Description Agreement:

This job description is intended to provide an outline of the key tasks and responsibilities only. There may be other duties required of the post-holder commensurate with the position. This description will be open to regular review and may be amended to take into account development within The Confederation. All members of staff should be prepared to take on additional duties or relinquish existing duties in order to maintain the efficient running of the service or function.

This job description is intended as a basic guide to the scope and responsibilities of the post and is not exhaustive. It will be subject to regular review and amendment as necessary in consultation with the post holder.

Person Specification:

Essential Criteria:

• Be willing to attend training with a non-clinical Supported self management health coaching skills programme (minimum 4 days) by a Personalised Care Institute (PCI) accredited trainer or organisation prior to taking referrals
• Experience of using coaching approaches/frameworks and models or other helping strategies e.g. Motivational Interviewing
• An understanding of the biopsychosocial model of health and the social determinants of health.
• Demonstrate the ability to communicate complex and sensitive information in an understandable form to a variety of audiences (e.g. patients).
• Understanding how to apply health coaching in group settings

Desirable Criteria:

• Specialist knowledge acquired through postgraduate diploma level or equivalent training/experience
• Coaching/counselling qualification/ experience or other relevant qualification/experience involving reflective listening skills relevant training and experience in non-clinical Supported Self-Management (SSM) Health Coaching through a PCI-accredited organisation
• Experience of working in health and social care care/community development setting or similar
• Understanding of the importance and process of helping people with long-term conditions to develop their knowledge, skills and confidence in managing their health and the range of models and tools available.