Key responsibilities Work with people, their families and carers, to improve their understanding of their condition. Support people to develop and review personalised care and support plans to manage their needs and achieve better healthcare outcomes and continuity of care. Help people to manage their needs by providing a contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care. Signpost patients where appropriate to other additional roles within the PCN for example Social Prescribers and Health & Wellbeing coaches.
Provide co-ordination and navigation for people and their carers across health and care services. Helping to ensure patients receive a joined-up service and the appropriate support from the right person at the right time. Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer back to other health professionals within the PCN. Support the co-ordination and delivery of multidisciplinary teams with the PCN.
Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and people to be more prepared to have shared decision-making conversations. Process and book appointments by telephone or written format as requested via practice. Process referrals to community nursing and other professionals

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