Job Description

Support the CPMG team and General Practices in the identification of appropriate patients for care planning and case management. Liaise with a range of health and social care providers including primary, community, social,third sector and secondary care to collate the necessary information about the patients forcare planning and case management. Support patients and their nominated relatives through the care planning and case management process. Provide administrative, communication and performance management support at individual GP Practices as well as within the CPMG team.



Be able to plan, organise and have good time management skills to prioritise their own workload. Work with a list of named patients with the aim of encouraging independence, alongside the GP and CPMG team, enabling people to remain at home. Reducing unnecessary admissions tohospital or attendance at A & E and supporting timely discharge from the Virtual ward. Provide feedback to the Practice and CPMG team, troubleshoot and escalate actions as necessary.



Facilitate and ensure the effective delivery of patient-centred, personalised health and social care for patients, monitoring progress and reporting outcomes to the GP, Senior Nurse Case Manager and the CPMG team. Contribute to patient reviews and care planning within appropriate time frames. Liaise between services and service users, contacting services using the appropriate procedures. Facilitate effective delivery of patient-centred, personalised health and social care for patients, by monitoring progress and reporting outcomes.



Ensure personalised care plans remain up to date and that they are evaluated and revised as necessary. Ensure contact is made with each person 'accepted' onto the CPMG and the proposed plan of care is communicated following liaison with the Senior Nurse Case Manager.