To undertake a holistic full assessment of the physical and psycho-social care needs of complex and frail patients and those with long term conditions, involving carers and relatives. To establish an individuals functional capabilities with regards to frailty, as well as ability to manage other long-term health conditions. To provide cognitive assessment and identification of mental health needs, referring as appropriate. To identify an individuals principle needs and support them in the development of plans to address related issues, supporting self-management where feasible. To develop a person centred, evidence-based holistic health and social care plan in conjunction with medical/other health professionals and social care colleagues. To provide co-ordination of clinical case management for complex and frail patients and those with long term conditions, who are at risk of declining clinical quality of life or avoidable hospital admission. To discuss assessment outcomes with patients, carers, their GPs and other health and social care professionals. To liaise closely with other health and social care professionals to provide community care and support to meet the needs of an individual. To identify social isolation and loneliness, being proactive in sign-posting to relevant resources to empower patients to remain active and engaged within their communities. Work closely with the social prescribing team. Using a high level of communication and interpersonal skills, establish effective working relationships with patients, their families and carers. To recognise and identify a deterioration in an individuals health and act promptly to reduce risk of rapid deterioration or where appropriate avoid hospital admission. Refer onto relevant health professional as required. To educate individuals and carers/relatives to identify early warnings of deterioration in order to facilitate rapid management of complication or crises. To facilitate early discharge, where possible, from hospital for case managed patients by co-ordination of care and services to be delivered within primary care/community. To identify those individuals with more complex health needs and refer for an holistic, multi-dimensional, interdisciplinary assessment with members of the MDT specialising in older peoples health and/or specialising in long term conditions, to include appropriate specialist secondary care expertise. To participate in the MDT meetings, where appropriate identify patients that may require an MDT review.