Working closely with Primary Care Network Clinical Directors and take direction from them as to the needs of the service. To work alongside clinical and non-clinical staff within GP surgeries to identify and receive referrals for individuals who would benefit from support within the community to address their non-clinical needs. To support individuals to undertake a holistic self-assessment, based on the persons priorities, and co-design a simple personalised care and support plan, identifying support needs to ensure maximum engagement in improving health and wellbeing and enable individuals, and their families and carers to live independently and improve their health outcomes To support individuals to access service and activities and make connections within their community and address their needs and desires as identified in their Personalised Care Plan. To provide individuals with a coordinated service, remaining point of contact throughout as required. To attend and input into multi-disciplinary team meetings as required to develop and inform individual care plans. To undertake follow up assessments with individuals at set intervals and according to agreed review timescales, as required. To keep accurate records using agreed systems and contribute to programme evaluation. To work according to confidentiality and data sharing policies of OurNet Health Services Ltd, the Walsall PCNs and its relevant partners. To develop strong personal networks and relationships within GP surgeries and voluntary and community groups. Manage and prioritise their own case load, in accordance with needs, priorities and any urgent support required by individuals on the case load. Where required and appropriate refer people back to other health professionals within the primary care network. Support staff within the primary care network with information about local voluntary and community resources and how patients can access them.