Be the first point of contact to identified patients, performing an initial evaluation ie Comprehensive Assessments and personalised care plans. Co-ordinate with the full Complex Care MDT to best action findings from the initial assessment. Offer a holistic service to our Complex Care patients, developing where appropriate an on-going plan of care/support, with an emphasis on prevention and self-care. Collaborative working with the practices to deliver ongoing priorities to our patients ie Comprehensive Assessments and personalised care plans. Help reduce the patient footprint into General Practice. Help reduce avoidable unplanned hospital admissions by improving services for vulnerable patients and those with complex physical or mental health needs, who are at high risk of hospital admissions or re-admissions. Working with hospitals to ensure that practices receive timely information on when patients are admitted to hospital and when they are likely to be discharged from hospital and to plan better handover arrangements. Conduct Acute visits to manage on the day demand and support the Practices, within scope of practice and competencies. Ensure proactive care management- carrying out reviews of all unplanned GP appointments/OOH contacts, A&E admissions, re-admissions and A&E attendances for patients. Ensuring follow up and coordination of patient care after discharge from hospital. Taking responsibility for own development, learning and performance and demonstrating skills and activities to others in the team and ensure own educational commitment is at least sufficient to maintain revalidation requirements.