Transition Care Package Coordinator

**Department**:Community Health

Direct: Nurse Unit Manager - Beaufort campus
**Reporting to**:
Indirect: Director of Clinical Services

**Classification / Code**:HS5.3- Dependent upon skills and experience

Victorian Public Health Sector (Health Professionals, Health and Allied
**Award Coverage**:Services, Managers & Administrative Workers) Single Interest Enterprise

Agreement 2016-2020

**Beaufort & Skipton Health Service**

**Vision**
To be a vibrant provider of care.

**Mission**
To enable all people in our community to be connected, healthy and live well.

**Values**

Teamwork, Compassion, Accountability, Respect, Excellence

**Beaufort and Skipton Health Service**

Beaufort and Skipton Health Service is a small rural health service that was formed on 1 October 1996

following the amalgamation of the Ripon Peace Memorial Hospital and the Skipton and District Memorial

Hospital.

The Health Service provides Urgent Care, Primary Care, Acute Inpatient, Residential Aged Care (Nursing Home

and Hostel level care), and a Transition Care Program (TCP). Community and Allied health and home based

services include District Nursing, Home Care packages, Respite, Health Promotion, Diabetes Education and a

large range of support programs.

Medical Clinical operates at Skipton along with specialist services that are available. Beaufort and Skipton

Health Service serves nearly 6,000 people in Beaufort, Skipton and the surrounding area.

**1. Purpose of Position**

The Transition Care Program (TCP) Care coordinator provides assessment, support, care planning and case
management to eligible clients and their cares in a bed based program or in a home based service.
The coordinator will develop collaborative relationships across the health service and community programs
to provide high quality case management. The TCP Coordinator will support the timely management of TCP
clients as they complete their restorative process, optimise their functional capacity, finalise, and access
their longer-term care arrangements. Will act as the central point of contact for all involved in the care of
the client.

**2. Key Responsibilities**

**Personal & Professional Development**
- Active participation in all ongoing performance appraisals and with manager develop an annual work

plan.
- Evidence of actively managing professional development.
- Completion of all Mandatory training requirements

**Customer Service**
- Act as advocate for clients where deemed appropriate.
- Liaise with service providers to keep them advised of changes required in care plans.
- Develop discharge plans in consultation with clients, their families, and the multidisciplinary team and

effectively coordinate support as required.

**Administration & Documentation**
- Maintain timely, accurate and appropriate documentation in relation to all client care issues.
- Actively manage budgetary requirements and adhere to both program and organisational policies and

procedures in relation to expenditure.
- Prepare all reports, finding submissions, educational materials and other relevant documentation.
- Collect data required as per reporting requirements.

**Technical Skills & Application**
- Evidence of best practice management of the TCP program.
- Evidence of appropriate contemporary knowledge and skill sets to coordinate the TCP program.

**Teamwork & Communication**
- Commitment and contribution as a member of a multi-disciplinary team.
- Participate in team meetings, case conferences and engage in appropriate consultations with relevant

stakeholders.

**Quality / Safety & Risk Management**
- Actively participate in quality improvement activities.
- Identify clinical risk through incident reporting (VHIMs), analysis and record review.

**Qualifications**:
**Essential**:

- Registered Nurse, Social Worker or Allied Health Professional with relevant professional body.
- Experience in undertaking complex assessment and care coordination of clients in a community,

acute and residential setting
- Demonstrated ability to identify and actively participate in quality improvement activities and

positively influence change.
- Ability to provide goal centred care coordination, dependent on the client carer needs and safety

requirements.
- Current Victorian Driver’s License
- Knowledge of Transition Care Program

**Desirable**:

- Able to demonstrate highly developed interpersonal skills, including excellent written and verbal

communication, negotiation and conflict resolution skills.
- Ability to work autonomously and collaborate effectively in a multi-disciplinary team to achieve

desired client outcomes.***

**BSHS Accountabilities**:

- Compliance with all BSHS Policies and Procedures.
- At all times practices works within the vison, mission and values of Beaufort and Skipton Health Service.
- Adherence to infection control policies and procedures as identified in the Beaufort and Skipton Health

Services Infection Control Manuals.
- Participation in the BSH