Care coordinators will: Proactively identify and work with a cohort of patients to support their personalised care requirements, using the available decision support aids. For example those patients with a Learning Disability, Mental Health, Dementia and vulnerable/frail patients. Bring together all of a persons identified care and support needs and explore their options to meet these into a single personalised care and support plan (PCSP) based on what matters to the person, ensuring dignity, choice, respect, independence and rights are upheld at all times. Help people to manage their needs, answering their queries and supporting them to make appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care. Identify barriers to or issues preventing greater engagement and/or uptake by patients actively participate in developing solutions for patients and service providers. Support people to take up training and employment, and to access appropriate benefits where eligible. Raise awareness of shared decision making and decision support tools and assist people to be more prepared to have a shared decision-making conversation. Ensure that people have good quality information to help them make choices about their care, e.g. Support people to understand their level of knowledge, skills and confidence when engaging with their health and wellbeing. Assist people to access self-management education courses, peer support or interventions that support them in their health and wellbeing. Provide coordination and navigation for people and their carers across health and care services, alongside working closely with social prescribing link workers, health and wellbeing coaches and other primary care professionals. Support the coordination and delivery of Multi-Disciplinary Team (MDT) meetings within practice. Support patients with poor attendance records in vulnerable patient groups. Support the paediatric ADHD/Autism (ASD) referral pathway Any other duties as requested by your line manager.