Enable individuals with long term conditions to manage their medicines and their conditions independently Co-ordinate and review the delivery of care plans to meet the needs of individuals with long term conditions or complex needs Develop risk management plans to support individuals' independence and daily living within their home Lead on frailty and coordinate the monthly frailty meeting with the frailty consultant, BICS GP and the wider MDT Work closely with the Frailty Care Coordinator to ensure all data required is captured from the frailty meeting Use and develop methods and systems to communicate, record and report Present individuals needs and preferences Procure services for individuals Manage the use of physical resources Support the protection of individuals, key people and others Develop practices which promote choice, well-being and protection of all individuals Assess the health care needs of individuals with long term conditions and agree care plans Enable individuals with long term conditions to make informed choices concerning their health and well-being Support individuals to live at home safely and as independently as possible Build a partnership between the team, patient and carers Build partnerships with the local services to Banstead being proactive in your approach around early interventions. Work very closely with the Care Coordinators within the proactive team to ensure that all needs are met i.e. social, emotional, loneliness Promote, monitor and maintain health, safety and security in the working environment (Including use of risk assessments) Identify mental health needs and/or other health related issues Refer individuals to mental health and / or other services Contribute to the assessment of needs and the planning, evaluation, and review of individualised care plans of patients Implement specific parts of personlised care plan using a comprehensive geriatric assessment Enable patients to access psychological support Empower families, carers and others to support individuals with long term conditions Empower individuals with long term conditions to represent their view and organise their own support, assistance and action Help individuals with long term conditions to change their behavior to reduce the risk of complications and improve their quality of life Assist individuals to evaluate and contact support networks Enable people with long term conditions to cope with changes to their health and well-being Provide clinical leadership and take responsibility for the continuing professional development of self and others (including a mentorship role) Promote the values and principles underpinning best practice and share best practice Develop, sustain and evaluate collaborative work with othersPlease refer to the Job Description and Person specification for more details.