Proactively identify and work with cohorts of patients to deliver personalised care. Support patients to utilise decision making tools to prepare for shared decision-making conversations. Working holistically, bring together their identified care and support needs and explore options to meet these within a single personalised care and support plan (PCSP). Help people to manage their needs by answering their queries, making and managing appointments, providing good quality written or verbal information to inform decision making and enhancing their knowledge, skills and confidence. Support people to take up employment and training and to access appropriate benefits through referral to the Social Prescribing Link Workers. Connect patients with tools to support them, such as self-management education, peer support and the adoption of healthy behaviours. Provide co-ordination and navigation for people and their carers across health and care services, working closely with the Social Prescribing Link Worker, Health and Wellbeing Coaches and other health professionals. Support the co-ordination of MDTs across the PCN. Raise awareness of the benefits of shared decision making and decision support tools, how to use these and how to identify patients who may benefit from this approach. Ensure all VCSE organisations have appropriate safeguarding procedures in place and are genuine opportunities for patients to develop a sense of belonging, build knowledge, skills, and confidence. Discuss concerns with a relevant GP to ensure safeguarding procedures are followed appropriately.