Role purpose
Provide care management and clinical oversight to Support at Home Program (SaH) customers ensuring supports and services are delivered in accordance with the strengthened aged care standards, program guidelines, the persons goals, support needs and budget, in a consumer directed care model focusing on wellness and reablement.
Key Outcomes
- Provide care management services for a case load of SaH customers ensuring the effective delivery of supports and services in accordance with the care plan, budget, all regulatory and legislative requirements.
- Provide clinical oversight for SaH customers receiving short term funding for transitional care, restorative care, end of life and clinically related AT-HM products and services.
- Apply care management specialist skills and knowledge to identify, assess and manage the supports and services for older people with complex needs.
- Conduct care and service planning activities to ensure the successful onboarding of SaH participants making sure all customer documentation is available, understood, verified and maintained in the customer management system (CMS).
- Provide comprehensive care management, service planning and coordination activities for customers including, but not limited to:
- Identifying and implementing services to meet customers’ individualised goals and needs.
- Supporting and maintaining meaningful connections with family/carers, networks and the community.
- Increasing customers’ opportunities for enhancing quality of life, optimising safety, health, wellbeing, independence, social connections and community engagement while applying a wellness and reablement approach.
- Regularly reviewing and evaluating a customers’ program of supports, short-term funding pathways, care plan, quarterly budget, services and responding to any incidents, issues or reported decline in health or wellness.
- Maintain comprehensive case notes and record keeping of care management activities in line with program and budgetary requirements.
- Providing customer and carer education and advocacy; support customers to connect to other health and external services and undergo support plan reviews when needed.
- Providing coaching and support to direct care workers to ensure the safe, effective and quality delivery of customer directed supports and services.
- Maintain regular contact with customers and their family/carers to ensure that services are beneficial and their needs continue to be met and goals achieved.
- Maintain confidentiality, respect privacy, and preserve the customers’ independence.
- Develop relationships across the community to foster networking, referrals and advocacy.
Knowledge and Skills
- Tertiary qualifications in nursing or allied health including APHRA registration.
- Advanced knowledge of current care management practices for older people.
- Advanced knowledge of new aged care regulatory and legislative frameworks and requirements.
- Exceptional customer service, communication and relationship management skills.
- Advanced time management skills and the ability to reorganise priorities to meet demands.
- Excellent team skills with the ability to influence, problem solve and resolve complex issues.
- Excellent computer skills and demonstrated experience with customer management systems.
- Ability to work independently in a hybrid workplace.
- NDIS Worker Check.
- Current Drivers Licence and roadworthy vehicle.
