The post holder will: Assist both Practices within the PCN to develop a range of initiatives that will benefit the health and well-being of our patients and staff such as Park Runs and Park Walks. Assist the clinicians within both Practices to identify patients who have been off on long-term sick or with multiple Fit Notes or disability, to work with them to help them to enter or get back into the workplace. Identify people with long term conditions and low knowledge skills and confidence to manage their health and wellbeing. Have responsibility for providing support to a cohort of patients who will benefit from proactive health management and care including being the single point of contact for the person or carer to simplify access and coordination of services. Play a health coaching role; teaching and supporting patients and carers to understand and manage their own conditions and maintain an independent lifestyle through health coaching techniques to encourage patient activation. Support the development of personalised patient care plans, liaising with the practice team, patient, carer and the complex care team as appropriate. Proactively outreaching to patients on a regular and agreed basis. Play an active role in regular practice MDTmeetings if required to discuss high risk and or complex patients, by gathering information and being prepared to update the team on patient progress towards goals etc as per their care plan Map and connect community activities and resources at a locality level including supporting the development of a network of community health champions. Support the delivery of community based public health initiatives such as physical activity, healthy eating and social connectedness. Build and maintain strong links with the voluntary sector to network and improve partnership working. Support delivery of systematic self-care support plans for those with COPD, diabetes, asthma and multiple long-term conditions. Understand when it is appropriate or necessary to refer people to other health professionals/agencies. Understand the barriers for individuals/groups in accessing support in the community and use this insight in developing community-based support, working as part of the wider social prescribing model. Promote the service within the Primary Care Network, both for users and clinicians, building positive working relationships. Contribute to and work with others to organise awareness raising events for services that help support people to improve their health and wellbeing. Communicate effectively with colleagues, patients and carers so that information is shared in order to meet patients needs. Have a key role in helping to raise the local populations awareness of the support, groups and opportunities available to assist them in achieving their health and wellbeing goals.