MAIN DUTIES Identification of vulnerable and frail patients using the risk stratification, and the E-Frailty Tool (Aristotle and EMIS). Holistic assessment, planning, implementation and evaluation of the patient; encouraging self-care, resilience and community involvement as appropriate. Prioritise health problems and intervene appropriately. Sign-positing to primary, secondary, and third sector services where necessary including the voluntary sector. Working closely with clinical teams across the Practice and wider community. Working in an integrated multi-disciplinary environment across the locality, linking closely with the relevant stakeholders where appropriate, and developing patient pathways. Working closely with the Social Prescriber Care Co-ordinator to manage patient care and monitor progress against improvements following care planning and sign-posting. Attendance at the ICC Monthly Meeting and weekly MDT (Multi-Disciplinary Team) to update on the progress of patient care, including quantitative performance information around care plans, and qualitative feedback from patients. Flexibility within the Clinical Care Co-ordinator role to enable the post and the work of the Practice to evolve further, and in conjunction with the wider stakeholder group. Other duties and activities involved in patient care in line with current clinical competencies Communication Demonstrate sensitive communication styles to ensure patients are fully informed and consent to treatment Communicate effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating Anticipate barriers to communication and take action to improve communication Act as an advocate when representing patients and colleagues Delivering a quality service Produce accurate, contemporaneous and complete records of patient consultation, consistent with legislation, policies and procedures Prioritise, organise and manage own workload in a manner that maintains and promotes quality Deliver care according to NSF, NICE guidelines and evidence-based care Participate in the maintenance of quality governance systems and processes across the practice Collaborate on improving the quality of health care Support and participate in shared learning across the practice and wider organisation Understand and apply legal policy that supports the identification of vulnerable and abused children and adults, being aware of statutory child/vulnerable adult health procedure and local guidance Work within policies regarding family violence, vulnerable adults, substance abuse and addictive behaviour, and refer as appropriate Team working Understand own role and scope, and identify how this may develop over time Prioritise own workload and ensure effective time-management strategies are used. Management of risk Manage and assess risk within the areas of responsibility, ensuring adequate measures are in place to protect staff and patients Monitor work areas and practices to ensure they are safe and free from hazards and conform to health, safety and security legislation, policies, procedures and guidelines Undertake mandatory and statutory training requirements Apply infection-control measures within the practice according to local and national guidelines Apply policies that reduce environmental health risks, are culturally sensitive and increase access to health care for all Participate in the local implementation strategies that are aligned to the values and culture of general practice Utilising information Use technology as an aid to management in planning, implementation and monitoring, presenting and communicating information Review and process data using accurate SNOMED codes to ensure easy and accurate retrieval for monitoring and audit processes Understand the responsibility of self and others regarding the Freedom of Information Act Learning and development Disseminate learning and information gained to other team members in order to share good practice and inform others about current and future developments Assess own learning needs and undertake learning as appropriate Make effective use of learning opportunities within and outside the workplace, evaluating their effectiveness and feeding back relevant information Provide an educational role to patients, carers, families and colleagues in an environment that facilitates learning