Working with patients, their families and carers, to improve their understanding of their health condition and supporting them in developing personalised care plans. Supporting patients to manage their needs and achieve better healthcare outcomes. Ensuring patients receive and understand information to help them make choices about their care. Working collaboratively with GPs and other primary care professionals to proactively identify and manage a caseload, which may include patients with long-term health conditions. Referring patients to other allied healthcare professionals as required. Maintain records of referrals and interventions to enable monitoring and evaluation of the service. Provide coordination and navigation for patients and their carers across health and care services, working closely with social prescribers and other health care professionals.