The Care Coordinator plays a crucial role in the Hospital Admission Risk Program, Post Acute Care and Sub-acute Ambulatory Care Services focusing on the management of chronic conditions and complex care needs.
The Care Coordinator Works With People Who
* have chronic health conditions and/or complex healthcare needs
* are experiencing multiple factors - social, environmental, financial and cultural - impacting on their health
* frequently use hospitals or are at risk of hospitalisation
* who would benefit from care coordination and self-management support
The Care Coordinator must have good knowledge in primary health care services and the ability to provide integrated client-centred care for our consumers with chronic and complex conditions.
Responsibilities Include
* Assisting in achieving consistency of care between acute and community-based services. This involves clear communication, linkages, and collaborative integrated care planning;
* Providing a holistic assessment of clients, care coordination, and self-management coaching support to help clients achieve self-management and lifestyle goals;
* Monitoring client progress and evaluating care plans in liaison with GP's and the multidisciplinary team at all stages of client care provision;
* Ensuring clear communication between services, preventing duplication of referrals and service delivery; and
* Undertaking advocacy roles where necessary, especially where there is a carer identified.
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