Care Coordinator 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.
