Job summary a) To deliver multi-professional high quality care in the community, working with patients towards rehabilitation, self-management and independencethroughout the continuum of care.b) To participate in a team of colleagues supporting evidence based care,facilitating staff learning and development. Communication and working relationships a) Working in partnership, the post-holder communicates effectively with patients and their carers, the multi-disciplinary team and other key stakeholders on a range of complex health care matters, issues, ideas and situations.b) Acts as an information resource for patients, multi-disciplinary colleagues and other stakeholders. Responsible for signposting and referring individuals, families, carers and communities to the most appropriate agencies/services to support their needs.c) The post-holder may experience challenge in gaining concordance with the patient, families, or carers for any treatment plan. They may also experience resistance from other colleagues to an agreed action, or treatment option. Strong negotiating and influencing skills may be required. Key responsibilities a) Holistically assess, plan, implement and evaluate patient care whilst workingin an integrated manner with the multi-disciplinary team.b) Empower patients to work as partners in their care respecting individualchoice and difference and encouraging self-care where able. Supportingpatients in a programme of self-care/enablement. Main tasks a) Holistic assessment and care planning.b) Individualised care and the promotion of self-care.c) Safe and effective review and referral to the appropriate member of themultidisciplinary team.d) Effective delegation and prioritisation of workload.e) Professional development as required to maintain area of practice, and asnegotiated in supervision.f) An awareness of health, safety and security risks.g) Engagement in service provision and change.