Principal Duties & Responsibilities 1) Identify a persons care and support needs and explore their options to meet these into a single personalised care in collaboration with the patients primary care team. 2) Provide coordination and navigation for elderly people and their carers across health and care services, alongside working closely with social prescribing link workers, occupational therapists, dietitians. 3) Help people to manage their needs by referring onto the wider integrated care team. 4) To make patients feel more empowered and actively engaged to maintain independency. 5) Maintaining a register of patients who are over 80 and / or housebound across the PCN. 6) Face to face annual assessment review of patients social, physical and mental health needs. 7) Referring to other agencies depending on needs. 8) Participating in integrated care teams to ensure the co-ordination of care. 9) Be part of a PCN wide triage team, to support with capacity and access plans. 10) Support practices with Cancer screening programmes, supporting the PCN Cancer Lead with data collection and auditing. 11) Supporting practices with FIT testing and checking EMIS coding is correct. 12) Keep accurate time sheets and other data on the service. 13) Ensure observance and adherence to the Health and Safety at Work Act 1974. 14) Work to the agreed standards, policies and procedures and protocols of the Practices and PCN and be fully conversant with emergency procedures. 15) Carry out other duties as directed by the line manager/Practice Manager which are consistent with the duties and responsibilities of the post.