Please see job description and person specification for more details. Working alongside stakeholders: Nursing and other Clinical Staff GPs and Primary Care Teams Consultants of Secondary Care Walsall Healthcare NHS Trust Management Team Walsall Metropolitan Borough Council Service users and Carers. GP Practices and support staff Key Responsibilities Use skills and knowledge to support the needs of the patients in their own homes within 24 hours of hospital discharge. Including observations, medication checks, skin checks. To support short and long term care needs for patients in order to prevent unnecessary re-admissions to hospital. Able to effectively communicate at all levels of the organisation; to a variety of health professionals; users and carers, to provide the best outcomes Able to provide the interface between hospital and Primary, Community & Social Care settings. Able to challenge systems, professionals and decisions and effectively communicate the rationale for such challenges. Able to keep accurate contemporaneous documentation and care/ plans To support with the reduction in avoidable hospital admissions To use electronic alerts/ databases (CANAR, whiteboards) to assist with communication. To have a close collaborative working relationship with the high intensity user team. To assess risks to patients which need to be managed in relation to their health and well-being.