To assess and provide advanced level interventions for patients with long term conditions to achieve quality of life and independence where possible. To work within the integrated team to prevent unnecessary admission to hospital. To work with all health care professionals, and statutory/non-statutory agencies to provide a seamless, integrated service to our service users. To support patients in coordinating their personal health plans. To assess patients for assistive technology where appropriate. To refer on to social care support where appropriate. To support and manage Band 6 Case Manager Use effective communication, negotiating and influencing skills to introduce new systems of working to improve the pathway of patients who are very high intensity users of health care and/or at high risk of hospital admission.