1. Main Duties Of Job Contacting patients by telephone / email / text message / letter to make appointments for Health Care Assistants, Nurses, Nurse Practitioners, GPs as required for long term condition management as specified by practice. Support triage of information received via AccuRx or via other platforms. Administration support for the practice team. Use internal and external email and the internet to keep up to date and send and receive messages. Supporting patients with referral to external services such as Social Prescribing and befriending services. Respond, using a helpful and problem-solving approach, to all queries and requests for assistance from staff and other visitors. 2. Technical and Administrative Use SystmOne to access patient records, book blood tests and arrange routine appointments with the appropriate clinician. Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care. Provide expertise to address both the public health and social care needs of patients, including lifestyle advice, service information, and help in tackling local health inequalities. Ensure appropriate onward referral of urgent issues to an appropriate clinician. Support the coordination and delivery of multidisciplinary teams. Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients in having these conversations. Maintain records of referrals and interventions to enable monitoring and evaluation of service. Ensure appropriate SNOMED codes are used to record activity. 3. Enable Access to Personalised Care and Support Have a positive, empathetic, and responsive conversation with the person, and their family and carer(s) about their needs. Work towards increasing patients understanding of how to manage and develop health and wellbeing through offering advice and guidance. Work with the wider PCN, MDTs and the social prescribing service to look at how to support patients requiring personalised care and support. Support patients as guided by the practice to manage health inequalities. 4. Coordinate and Integrate Care Making and managing appointments for patients, related to primary, secondary, community, local authority, statutory, and voluntary organisations. Help people transition seamlessly between secondary and community care services, conducting follow-up appointments, and supporting people to navigate through wider the health and care system. Refer onwards to social prescribing link workers and health and wellbeing coaches where required. Regularly liaise with the range of multidisciplinary professionals and colleagues involved in the persons care, facilitating a coordinated approach and ensuring everyone is kept up to date so that any issues or concerns can be appropriately addressed and supported. Actively participate in multidisciplinary team meetings in the PCN as and when appropriate. Identify when action or additional support is needed, alerting a named clinical contact in addition to relevant professionals, and highlighting any safety concerns. Record what interventions are used to support people, and how people are developing on their health and care journey. Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonable required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner. Identify opportunities and gaps in the service and provide feedback to continually improve the service and contribute to business planning. Work in accordance with the practices and PCNs policies and procedures. Contribute to the wider aims and objectives of the PCN to improve and support primary care.