For further information on this role, please see the attached detailed Job Description and Person Specification To identify appropriate patients in the outpatient setting and also those who may be occasionally referred from the hospital setting and to assess their community needs in order to facilitate a seamless and safe discharge into the community. To communicate directly with members of the community MDT including GPs, community palliative care teams, district nurses and any other health care professional involved directly in the patients discharge. To arrange telephone/face to face conferences with community colleagues and to participate in these meetings either by telephone or in the patients preferred place of care. Along with the Matron/Nurse Consultant Palliative Care support educational initiatives for community and primary care providers to improve knowledge and to empower local teams to provide supportive and palliative care services to patients in their own homes. To work with patients and their families to ensure a smooth transition between primary, secondary and tertiary care services.