To assess and provide advanced level interventions for patients with long term conditions to achieve quality of life and independence where possible, and to support them in their own environment. To work within the integrated team to facilitate early discharge from hospital. To work in conjunction with Norwich Practices supporting the Home Visiting Service with long term condition management. To work within the integrated team to prevent unnecessary admission to hospital with adequate management plans and clear guidance. To work with all health care professionals, and statutory/non-statutory agencies to provide a seamless, integrated service to our service users. To support patients in coordinating their personal health plans. To assess patients for assistive technology where appropriate. To refer on to social care support where appropriate. To support and manage Band 6 Case Managers Track patients who are part of the Community Matron caseloads when entering hospital or nursing home step-up beds and ensure that they are followed up appropriately when discharged. Working closely with GPs and the acute hospital and support service issues that may need resolving to ensure timely discharge. Proactively find patients who are very high intensity users of primary and secondary healthcare and/or are at high risk of unplanned admission to hospital. Educate and support the members of the multi-disciplinary teams to intensively case manage these patients. Intensively manage their own caseload of patients with highly complex and unstable health needs. Independently manage the caseload by maintaining a consistent throughput of patients. This should be achieved by; ensuring patients are discharged in a timely manner; promoting patient independence in managing their own health conditions; encouraging self-care and condition self-management; sign posting to other appropriate services; and by utilising strategies of health promotion and health coaching. Develop systems and processes to support intensive case management within the multidisciplinary team and with partners across the health system. Work with and refer appropriately to other agencies to enable identified patients to be intensively managed in a pro-active way with the aim of preventing hospital admission, supporting early discharge and reduce GP contact. Accountable for the intensive case management and where appropriate intervention of a defined patient caseload. Actively work with GPs and other agencies, and with appropriate information technology, to case find patients. Be a champion for people with long term conditions. Provide supervision and assessment for all learners as part of trust educational policy, particularly those undertaking pre/post registration nursing courses.