The post holders, working closely with the PCN team, care homes, GP Practices and existing community services will: Work collaboratively with other teams and services to maintain an effective and efficient service. Plan and organise work using own initiative, whilst being able to work as a valuable team member. Be able to make referrals to relevant service providers. Coordinate and where required chair MDT meetings, having proactively prepared any actions prior to the meeting and ensure all relevant clinical and non-clinical staff are present. To promote and facilitate integration within the GP and community teams. To provide and receive sensitive information about difficult or complex matters always respecting confidentiality. Create detailed and clear minutes from the meetings and forward to all relevant parties with actions highlighted to individuals. Where required, be able to offer appropriate support and guidance to patients and families / carers. Receive, record, and collate information and maintain accurate electronic records of patient care and planned service provision, including hospital admission and discharge information. Signpost service users and carers to relevant services. Contribute to quality audits. Cooperate and support colleagues to share best practice, complete tasks to maximise effectiveness and team performance. Take part in appropriate training and take responsibility for own personal development. Contribute to the development of the role and systems, to effectively enhance the service provided and improve outcomes. To assist patients to be better prepared to have conversations on shared decision making and to improve awareness of shared decision making and related support tools. To provide patients with high quality, easy to understand information to assist them in making choices about their care. To support in the delivery of enhanced services and other service requirements on behalf of the PCN Support delivery of QOF or cost effectiveness initiatives Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner. Duties may vary from time to time without changing the general character of the post or the level of responsibility.