
Transition Care Programme Specialist
3 days ago
Care Programme Manager
Job DescriptionThe Transition Care Programme is a service that supports older adults as they transition from hospital to community-based care.
Our team works closely with hospitals, aged care agencies, primary health care and General Practice to ensure that older adults are discharged to appropriate rehabilitation services.
We facilitate Aged Care Assessments to guarantee safe and suitable transfer of individuals to our programme or other dependent services.
As a key member of our team, you will assist the Nurse Unit Manager in planning, coordinating and accepting clients to our programme. You will be accountable for your own practice standards and activities delegated to others, and provide guidance and development of less experienced staff.
Responsibilities- Liaise with hospitals to identify suitable older adults within CALHN inpatient services
- Ensure that older adults who are identified to be part of the programme are discharged to appropriate rehabilitation services
- Develop short-term care coordination plans for those patients assessed
- Establish ongoing case management in the community following patient discharge from the programme
- Maintain effective service linkages, particularly across aged care agencies, primary health care and General Practice
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