Work with individual practice teams and primary care professionals within the PCN to identify and manage a caseload of patients Work closely and in partnership with PCN colleagues including Social Prescribing Link Workers, Health Coaches and Clinical Pharmacist(s). Signpost team members, patients and carers to relevant services as appropriate Make referrals to the multi-disciplinary team as appropriate Central co-ordination role around proactive support and care planning for agreed patient cohorts (cancer specifically for this role) Support patient independence, promote healthcare and well-being including the use of digital apps to support their care Supporting patients and carers to utilise decision aids when appropriate Support patients to have shared decision making conversations Empower patients, this may include the use of validated PAM tools Facilitate smooth and planned discharge and handover between care settings across the health and social care system, including GP, acute, community, and be responsible for facilitating inter-agency communication and support Support people to take up training and employment, or to access appropriate benefits where eligible for example, through referral to social prescribing link workers; Assist people to access self-management education courses, peer support or interventions that support them to take more control of their health and wellbeing; Use healthcare technologies to optimise service delivery, access, and continuity of care for patients and carers Use Population Health Intelligence and Risk Stratification tools proactively to identify groups of patients for MDT discussions or to deliver health services May attend and present at MDT meetings or local schools May support the coordination and delivery of surgery MDT meetings May support in the setting up and administration of Group Consultations Opportunity to develop and shape this service Perform any duty specifically delegated by your line manager as being properly the responsibility of this post. The tasks and responsibilities in this job description may change in the light of developments within the surgery or practice and are subject to review.