Basic Purpose of the Role To collaborate with GP surgeries, care homes, paramedics, and attached teams to deliver high-quality care for care home residents. Key Duties Enable access to personalised care and support a. Take referrals for individuals or proactively identify people who could benefit from support through care coordination. b. Have a positive, empathic, and responsive conversation with the person and their family and carer(s) about their needs. c. Support people to develop and implement personalised care and support plans. d. Review and update personalised care and support plans at regular intervals. e. Ensure personalised care and support plans are communicated to the GP and any other professionals involved in the persons care and upload the relevant online care records, with activity recorded using the relevant SNOMED codes. f. Where a personal health budget is open, to work with the person and the local ICB team to provide advice and support as appropriate. Coordinate and integrate care a. Help people transition seamlessly between services and support them to navigate through the health and care system. b. Refer onwards to other healthcare agencies where required. c. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported. d. Actively participate in multidisciplinary team meetings in the PCN as and when required. e. Identify when action or additional support is needed, alerting a named clinician contact in addition to relevant professionals, and highlighting any safety concerns. Professional development a. Work with a named clinical point of contact for advice and support. b. Undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities, and provide evidence of learning activity as required. c. Attend any training courses and supervision sessions as required. d. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety. Miscellaneous a. Establish strong working relationships with GPs and practice teams and work collaboratively with other care coordinators, social prescribing link workers and other agencies, supporting each other, respecting each others views, and meeting regularly as a team. b. Report any Safeguarding concerns to the appropriate person c. Act as a champion for personalised care and shared decisional making within the PCN. d. Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level or responsibility of the role, ensuring that the work is delivered in a timely and effective manner. e. Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning. f. Contribute to the development of policies and plans relating to equality, diversity, and reduction of health inequalities. g. Work in accordance with the Practices and PCNs policies and procedures. h. Contribute to the wider aims and objectives of the PCN to improve and support primary care. i. Undertake any other duties as may reasonably be required from time to time. j. Ensure that all activities are monitored and evaluated.