Primary Responsibilities Coach and motivate patients through multiple sessions to identify their needs, set goals, and support them to implement their personalised health and care plan. Provide personalised support to individuals, their families and carers to ensure that they are active participants in their own healthcare; empowering them to take more control in managing their own health and wellbeing, to live independently and improve their health outcomes through: Providing interventions. Supporting people to establish and attain goals set by the person based on what is important to them. Working with the social prescribing service to connect them to community-based activities. Working with the Long-Term Conditions (LTC) team to deliver specific health advice, where appropriate. Working to increase the prevalence of treatable LTCs by undertaking health checks. Inputting data including appropriate disease and referral coding. Provide support to local community groups and work with other health, social care and voluntary sector providers to support the patients; health and well-being holistically. Help to establish and co-ordinate patient groups to aid self-management, peer support, and the creation of patient communities. Support colleagues to improve their skills and understanding of personalised care, behavioural approaches. Undertake all the necessary training and induction for the role. Raise awareness within the PCN of shared decision making and decision support tools and supporting people in shared decision-making conversations. Explore and support access to a personal health budget, where appropriate, for their care and support. Utilise existing IT and MDT channels to screen patients, with an aim to identify those that would benefit from health coaching. Work with the PCN and practices towards a number of different outcome and quality improvement measures including QOF, QIPP and IIF. Main Tasks Manage and prioritise a caseload, in accordance with the health and wellbeing needs of their population. Supporting practices teams in identifying patients who will benefit from the support and encouragement. Provide personalised support to individuals, their families, and carers to support them to be active participants in their own healthcare; empowering them to manage their own health and wellbeing and live independently. Helping them understand what is important to them and working with them to get there. Coaching, supporting, encouraging and motivating patients through multiple sessions to identify their needs, set goals, and support them in achieving their personalised health goals. Introducing patient support such as self-management education and peer support like group consultations. Supporting personal choice and positive risk taking while ensuring that patients understand the accountability of their own actions and decisions, thus encouraging the proactive prevention of further illnesses. Working in with the Social Prescribing Link Workers, Care Coordinators, Pharmacists clinical and non-clinical teams with in the PCN to connect patients to community-based activities which support them and help them to take control of their health and wellbeing. Explore and support patient access to a personal health budget, where appropriate, for their care and support. Support delivery of systematic self-care support plans for those with COPD, Diabetes, Pre-Diabetes, CVD and multiple long-term conditions. Interest in weight management, diabetes and group consultations desirable. Understand when it is appropriate or necessary to refer people to other health professionals/agencies.