Full or Partial Capability status. For this Capability, Solutions are required to meet a minimum of one MUST EPIC and associated acceptance criteria but not all MUST EPICs (where there are multiple MUST EPICS) to achieve Partial Capability Status, or; to meet all MUST EPICs and their associated acceptance criteria to achieve Full Capability Status.
Description
Social prescribing focuses on a Patient/Service User's needs in a holistic way, and helps to address the social, practical and emotional needs of Patients that can't (wholly) be addressed medically such as social isolation, reduced mobility, mental health issues or some long-term conditions.
Social prescribing provides the ability for Health and Care Professionals to refer a Patient/Service User - or for the Patient/Service User to self-refer - to one or more non-clinical interventions or services. This encompasses a wide variety of services such as activity groups (e.g. walking clubs), peer support groups, volunteer support, or information and guidance services, typically provided by Third Sector Organisations.
Models vary but in many cases, there is a Link Worker (also known as a Support Broker, Community Navigator or Champion) based in the Practice, Healthcare Organisation or in a Connector Scheme who works with Patients/Service Users to assess their needs and identify relevant services.
The Social Prescribing Capability is about the provision of integrated systems or Solutions that allow referral (the aspiration is electronically) of Patients/Service Users to Providers of appropriate and relevant interventions or services.
The Capability allows national and local directories of services to be accessed and allows providers offering such services within a locality to make these available via the Capability. The Patient/Service User or Health or Care Professional then chooses from the directory of locally available services and generates a referral. Subject to appropriate consent, a Patient/Service User's details can be passed to the Organisation delivering the service and data relating to social prescribing referrals can then be maintained as part of the Patient/Service User's clinical record (the aspiration is through integrated systems).
The draft version /wiki/spaces/GGD/pages/12626264154 doesn't not need to be archived because it's in the GEN2 space and not the Roadmap space.
Outcomes
Patient/Service User |
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Health or Care Professional |
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Managers and Commissioners |
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Voluntary / Community Sector or other Service providers |
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C37E1 - assess wellness or well-being of the Patient or Service User
As a Link Worker or other Health or Care Professional (GP, Nurse or other)
I want to be able to assess the wellness of a Patient/Service User using a methodology appropriate to the Patient/Service User's condition or circumstances
So that I can understand and record their non-clinical healthcare needs
Acceptance criterion 1: initial well-being assessment is captured
Given that a Patient/Service User has been referred
And the need for a well-being assessment has been identified
When the Link Worker (or other) undertakes a wellness assessment using a methodology appropriate to the Patient/Service User's condition, circumstances and / or need (e.g. Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS) or Wellbeing Star)
Then the outcome of the assessment can be recorded on the Patient/Service User's Social Prescribing record
Acceptance criterion 2: subsequent well-being assessments are captured
Given a Patient/Service User has been assigned a series of sessions or engagements with the service provider(s)
And the Patient/Service User and Link Worker (or other) have agreed to meet at regular intervals
When the wellness assessment is repeated
Then the outcome of second and subsequent assessments can be recorded on the Patient/Service User's Social Prescribing record
C37E2 - search the directory
As a Link Worker, Health or Care Professional or other member of the Practice/Healthcare Organisation team
I want to be able to search the Directory of non-clinical services and interventions (e.g. support groups, sporting activities, information or guidance services, etc.)
So that I can identify the services that are most relevant to a Patient/Service User's needs
Acceptance criterion 1: directory search returns services that match criteria
Given that a directory of services has been created in the Social Prescribing Solution
And criteria have been defined for each service (e.g. age or gender restrictions of use or relevance to conditions)
And the search criteria (e.g. specifying the age / gender of the Patient/Service User, their condition, geographic location or mobility status) have been defined
When a search is run against the directory
Then the list of services that match the search criteria are displayed
C37E3 - refer Patient/Service User to service(s)
As a Link Worker, Health or Care Professional or other member of the Practice/Healthcare Organisation team
I want to be able to refer a Patient/Service User to one or more non-clinical services
So that they can receive the most appropriate support for their non-clinical needs
Acceptance criterion 1: Patient/Service User is referred to a service
Given the Patient/Service User's needs have been understood
When one or more possible services have been identified matching their needs
Then the relevant service(s) can be selected
And a referral for each service for the relevant service provider can be created
C37E4 - maintain referral record
As a Link Worker or Health or Care Professional
I want to be able to maintain a record of assessments and referrals, including information about each referral (e.g. attendance, outcomes), for a Patient/Service User
So that G.P.s, Nurses and other Health and Care Professionals can understand the Patient/Service User's wider healthcare issues and needs
Acceptance criterion 1: Patient/Service User's attendance is captured
Given a Patient/Service User has been referred to a service
When information is received relating to the Patient/Service User's attendance (electronically or via a manual route such as telephoning the service provider)
Then the Patient/Service User's record can be updated
And their attendance or non-attendance can be recorded
And this information is available to those other Health and Care Professionals (e.g. GPs, Nurses) with appropriate access to the record
Acceptance criterion 2: Patient/Service User's outcomes are captured
Given a Patient/Service User has been referred to a service
And has attended some or all the referred sessions
When information relating to the Patient/Service User's outcomes is received in relation to using the service, electronically or via manual route (such as telephoning the service provider)
Then the Patient/Service User's record can be updated
And their outcomes recorded
And this information is available to those other Health and Care Professionals (e.g. GPs, Nurses) with appropriate access to the record
C37E5 - link to national or local directory of services
As a Link Worker or Administrator
I want the Social Prescribing Solution to be able to link to or make use of national or local directories of services
So that the directory includes a broader range of available and relevant services with the minimum maintenance overhead for my Practice/Healthcare Organisation
Acceptance criterion 1: link to national directory of services
Given that national directories of services (e.g. e-Referral Service or 111) are available
When one or more national directories of relevance are identified
Then the national directory (or directories) can be linked to or accessed via the Social Prescribing Solution
And the national directory can be searched
Acceptance criterion 2: link to local directory of services
Given that local directories of services (e.g. the Leeds Directory) are available
When one or more local directories of relevance are identified
Then the local directory (or directories) can be linked to or accessed via the Social Prescribing Solution
And the local directory can be searched
C37E6 - maintain directory of services
As a Link Worker or Service Administrator
I want to be able to manually maintain (add, update or delete) the directory of services
So that the directory is always up to date and reflects the full range of services available
Acceptance criterion 1: new service is added to the directory
Given that a directory of services has been created in the Social Prescribing Solution
When a new service is identified that does not appear in any linked local or national directories
Then details of this new service can be manually added to the directory
Acceptance criterion 2: existing service is updated in the directory
Given that one or more services have been created manually in the Social Prescribing Solution
When the details relating to a service change
Then the details of the service can be updated in the directory
Acceptance criterion 3: existing service is withdrawn or no longer available
Given that a directory of services has been created in the Social Prescribing Solution
And details of the service exist in the directory
When a service is withdrawn (closes or is no longer available for referrals)
Then the details of the service can be updated such that it doesn't appear in searches
And Patients / Service Users can no longer be referred to the service
C37E7 - maintain service criteria
As a Link Worker or Service Administrator
I want to maintain (add, update or remove) information about services (such as any restrictions on usage or fit with Patients' conditions or circumstances)
So that the directory is always up to date and reflects the services available
Acceptance criterion 1: Restrictions on usage are applied to a service
Given that a directory of services has been created in the Social Prescribing Solution
When restrictions on or criteria for usage of a service are identified (e.g. minimum or maximum age of Patient/Service User or their gender)
Then information about the service can be updated
And the service will only be returned in searches that specify matching service restrictions (including no service restrictions specified)
Acceptance criterion 2: Relevance of service to Patient/Service User's circumstances or conditions is captured
Given that a directory of services has been created in the Social Prescribing Solution
When a service is identified as being relevant for Patient/Service Users with circumstances (e.g. they are a carer) or with conditions (e.g. dementia, depression)
Then information about the service can be updated
And the service will only be returned in searches specifying matching conditions or circumstances (including no conditions / circumstances specified)
C37E8 - refer Patient/Service User to Link Worker
As a Health or Care Professional
I want to refer a Patient, who has highlighted a healthcare issue to a Social Prescribing Link Worker (may also be known as a Support Broker, Community Navigator, Champion, Well-being Co-ordinator or other term), based in the Healthcare Organisation (e.g. the Practice) or a Connector Scheme
So that the Link Worker can contact and assess the Patient/Service User
Acceptance criterion 1: New referral to Link Worker is created
Given the Healthcare Organisation offers a Social Prescribing Capability
And has a Link Worker based either in the Practice, Healthcare Organisation or in a Connector Scheme
When a healthcare issue is highlighted by a Patient/Service User
Then a referral for the Patient/Service User to the Link Worker can be generated
Acceptance criterion 2: Link Worker is notified of new referral
Given that a healthcare need has been identified for a Patient/Service User
And there is a Link Worker based either in the Practice, Healthcare Organisation or in a Connector Scheme
When a referral to the Link Worker is generated
Then the Link Worker is notified (by email, a task in a workflow or other means) that a new referral has been made
And the Link Worker can identify the relevant Patient/Service User in order to initiate contact
C37E9 - capture Patient/Service User consent
As a Link Worker, Health or Care Professional or other member of the Practice/Healthcare Organisation
I want to be able to capture Patient/Service User consent
So that I have a record of their wishes with respect to receiving non-clinical treatment and the sharing of their data
Acceptance criterion 1: Patient consent is captured
Given an appropriate service referral has been identified
When the Patient/Service User consents to being referred to the service provider
Then consent to non-clinical treatment can be captured or recorded on the Patient/Service User's record
And consent to share their data can be captured or recorded on the Patient/Service User's record
Acceptance criterion 2: Patient consent to non-clinical treatment is not obtained
Given an appropriate service referral has been identified
When the Patient/Service User refuses consent to non-clinical treatment by the service provider
Then lack of consent to non-clinical treatment can be captured or recorded on the Patient/Service User's record
Acceptance criterion 3: Patient consent is not obtained for information sharing
Given an appropriate service referral has been identified
When the Patient/Service User does not agree to the sharing of their data with the service provider
Then lack of consent to share data can be captured or recorded on the Patient/Service User's record
C37E10 - Patient self-referral
As a Patient/Service User
I want to be able to self-refer to services
So that I can quickly access support services relevant to my needs or condition
Acceptance criterion 1: Patient/Service User searches the directory of services
Given that a Patient/Service User has identified a healthcare need that can wholly or partially be met by a non-clinical treatment
And a directory of services has been created in the Social Prescribing Solution
And the directory is available to Patients/Service Users
And the Patient/Service User has the correct access enabling self-referral
When the Patient/Service User searches the directory for services (using an open search or specifying their condition or circumstances)
Then a list of services is displayed
And the Patient/Service User can select one or more services to which they want to self-refer
And a referral form for each service for the relevant service provider can be created
And the Patient/Service User can be referred to the service provider(s) automatically (for integrated systems) or manually (via letter, phone, email, web form, etc.)
C37E11 - integrate Social Prescribing Referral Record with Clinical Record
As a GP, Nurse or other Health or Care Professional
I want to be able to view a Patient/Service User's assessments and referrals as part of their clinical record
So that I can understand a Patient/Service User's healthcare issues and interactions with services in a more holistic way
Acceptance criterion 1: View social prescribing activities as part of clinical record
Given that the Social Prescribing Solution has been linked or integrated with the Clinical System
And a consultation or other interaction has been held between the Patient/Service User and their Link Worker or other Health or Care Professional
When updates are made to the Patient/Service User's Social Prescribing record (e.g. consultation notes, wellness assessment undertaken, referral to service, outcome of referral)
Then the updates are incorporated into the clinical record of the Patient/Service User
And can be viewed on the timeline for the Patient/Service User as part of the consultation history
C37E12 - receive notification of an Appointment
As a Link Worker
I want notifications relating to Appointments to be generated automatically and sent to defined recipients (e.g. the Patient/Service User and their Practice) by their preferred method (e.g. letter, email, Short Message Service (SMS))
So that they are aware of Appointments and any changes and can act on this information (e.g. make arrangements to attend, update records)
Acceptance criterion 1: Patient/Service User receives notification
Given that a Patient/Service User has been referred to a service
And their preferred method of communication (e.g. letter, email, SMS) has been captured
And the relevant contact details are recorded
When an Appointment is booked, amended or cancelled
Then the Patient/Service User receives a notification via their preferred method with the details of the booking, amendment or cancellation
Acceptance criterion 2: Patient/Service User's Practice receives notification
Given that a Patient/Service User has been referred to a service
And the preferred method of communication (e.g. letter, email, SMS) has been captured
And the relevant contact details are recorded
When an Appointment is booked, amended or cancelled
Then the Patient/Service User's Organisation receives a notification via the preferred method with the details of the booking, amendment or cancellation
C37E13 - remind Patients/Service Users of Appointments
As a Link Worker
I want to be able to issue reminders about Appointments to a Patient/Service User by their preferred method (e.g. letter, email, SMS)
So that the likelihood of them attending is increased
Acceptance criterion 1: Patient/Service User receives reminder
Given that a Patient/Service User has an Appointment with a Social Prescribing service
And their preferred method of communication (e.g. letter, email, SMS) has been captured
And the relevant contact details are recorded
And rules relating to reminders have been defined (e.g. how far in advance of the Appointment reminders are sent)
When the trigger point for an Appointment is reached
Then the Patient/Service User receives a reminder of the Appointment via their preferred method of communication
C37E14 - provide service feedback
As a Patient/Service User
I want to be to provide feedback on non-clinical services
So that I can share my experiences (e.g. experience of booking, effectiveness of the service) with other Patients/Service Users, Link Workers and other Health and Care Professionals
Acceptance criterion 1: Patient/Service User creates feedback
Given that a Patient/Service User has been referred to a service
And the Patient/Service User has access to the Social Prescribing Solution
When the Patient/Service User has engaged (or attempted to engage) with the service provider
Then the Patient/Service User can create feedback on the service
And the feedback is associated with the service
And the feedback can be viewed by other users of the Social Prescribing Solution
Acceptance criterion 2: Link Worker, Administrator or other creates feedback on behalf of the Patient/Service User
Given that a Patient/Service User has been referred to a service
When the Patient/Service User provides feedback on the service to the Link Worker or other team member
Then the Link Worker or other team member can create feedback on the service on their behalf
And the feedback is associated with the service
And the feedback can be viewed by other users of the Social Prescribing Solution
Acceptance criterion 3: Patient/Service User provides feedback anonymously
Given that a Patient/Service User has been referred to a service
When the Patient/Service User decides to provide anonymous feedback
Then the Patient/Service User can create feedback on the service using a guest or other anonymous account
And the feedback is associated with the service
And the feedback can be viewed by other users of the Social Prescribing Solution
Acceptance criterion 4: feedback is moderated
Given that an individual has been identified as a moderator for service-related feedback
And feedback has been created for a service
When feedback is identified as being unfair or inappropriate
Then the moderator can moderate (remove or hide) the feedback
And the feedback can no longer be viewed by other users of the Social Prescribing Solution
C37E15 - view service feedback
As a Patient/Service User or Link Worker
I want to be able to see feedback on non-clinical services used by Patients/Service Users
So that I can select services that have been most effective for Patients/Service Users with similar circumstances or conditions
Acceptance criterion 1: Patient/Service User views feedback
Given that a Patient/Service User has identified a service that might meet their health or well-being needs
And the Patient/Service User has access to the Social Prescribing Solution
And feedback has been captured in relation to the service
When the Patient/Service User views the details of the service
Then the Patient/Service User can also view any feedback recorded against the service
C37E16 - Obtain Management Information (MI) on Social Prescribing
As a Manager or Commissioner
I want to have access to management information relating to Social Prescribing
So that I can analyse the Social Prescribing data to understand usage (e.g. volume of referrals, number of Patients completing an intervention) and outcomes
Acceptance criterion 1: understand usage of Social Prescribing
Given that information relating to Social Prescribing has been created within the relevant Solution
And the user has access to the data
And the user has access to a reporting Solution
When a new reporting need is identified
Then a report can be designed to create output relating to the use of Social Prescribing
Suppliers will have to attain compliance with these Standards during the compliance stage before they can be live on a framework with this Capability:
None
Suppliers will have to attain compliance with these Standards during the compliance stage before they can be live on a framework with this Capability:
- Interoperability Standard
- Overarching Standards
Suppliers will not be assessed or assured on these Roadmap Items as part of Onboarding