The post holder will work autonomously and in collaboration with other healthcare professionals and statutory and voluntary agencies to deliver excellent standards of patient care for patients requiring support in planned care. Clinical responsibilities Undertake comprehensive, holistic assessments of individuals, including those with a complex presentation, using investigative, analytical & clinical reasoning skills, and formulate a treatment plan. Undertake functional assessments for patients by using investigative and analytical skills for those with acute/complex/rehabilitation or palliative care needs Liaise with GPs, social services, inpatient teams, other allied health care professionals, and the voluntary sector to ensure identified needs are met and care is coordinated appropriately. Communicate effectively with individuals and their carers to maximise potential and to aid motivation and understanding throughout the treatment process. Empower/enable patients and carers to maximise the potential for self-care. Required to use tact and persuasive skills in order to gain the individuals cooperation in their treatment plan. Be responsible for ensuring workload for self and others is planned and prioritised according to service targets and needs. Ensure patient-held records are completed for each visit and that SystmOne inputting is completed on a daily basis. Where safe care is not able to be sustained to liaise with the broader community services and care coordination centre to plan and implement appropriate actions