Ballan District Health & Care

Position Description

POSITION
/ REGISTERED NURSE DIVISION 1
Care Coordination Nurse
PURPOSE / The Care Coordination Nurse is responsible for delivering person-centred care to people with chronic conditions within the BDHC Primary Care framework.This includes health assessment, care planning, care coordination, and client education.
Ballan Community Health Centre provides an integrated multi-disciplinary environment to maximise health outcomes of community members.
KEY SELECTION CRITERIA / Essential
  1. RN Division 1 with current registration with AHPRA
  2. Excellent interpersonal and communication skills with patients, carers and with other members of the community health team
  3. Ability to work autonomously and collaboratively within a multidisciplinary team
  4. Basic to intermediate level of computer use (especially Microsoft Office Suite)
  5. Have experience or interest in community-based patient education and health promotion.
Desirable
  1. Experience working in a primary care setting – administering chronic disease management program
  2. Motivational interviewing and health coaching experience
  3. Experience working in care coordination/case management role
  4. Experience coordination and deliver of health promotion programs (eg: QUIT)

CONDITIONS OF EMPLOYMENT / According to the Ballan District Health and Care EBA
PHYSICAL STANDARDS
(approximate) /
  • Walk / Stand 50% of the time
  • Sit for documentation 40% of the time
  • Bend, squat up to 10% of the time

RESPONSIBLE TO / Practice Manager - all Nursing Staff Professionally Accountable to Director of Clinical Services
MAIN RESPONSIBILITIES /
  1. Demonstrates comprehensive and accurate knowledge and skills in providing episodic and ongoing care that is responsive to all clients and carers in the Primary Care Setting.
• Conducts accurate comprehensiveassessment of individuals presenting at the GP Clinic to improve outcomes and minimise adverse events
• Assesses and develops health care plans that direct health care interventions and activities
• Performs duties that include but are not limited to chronic disease management, ECGs, health assessments and spirometry.
• Identifies and provides comprehensive physical, psychosocial and emotional care for individuals and carers
• Provides health care services in accordance with Medicare Benefits Schedule conditions.
2. Conducts diagnostic activities in collaboration with the general practice team.
• Demonstrates proficiency in health assessment skills
• Discusses diagnostic results with client and liaise with GP.
3.Initiates and conducts comprehensive health maintenance and health promotion in partnership with individualsand the primary care health team.
• Undertakes health screening and health monitoring activities such as cardiac assessment including electrocardiographs
• Involved in chronic disease management activities such as preparing a management plan, coordinating care, and providing education about self-help strategies in conjunction with the GP
• Oversees and manages a comprehensive recall system as per RACGP guidelines and standards
• Ensures that all information about chronic disease management, immunisation and wound care is accurate in accordance to Best Practice principles, standards, and guidelines
• Design holistic pathways in consideration of ongoing needs of the individual
• Regularly reviews and updates individuals’ information and resources.
4. Uses best available research to inform clinical care management.
• Collaborates with the industry governing bodies, general practice and health product provider representatives to access current information
• In conjunction with GP team, reviews practice guidelines and protocols based on evaluation of research outcomes and evidence
• Participates in research taking place in the general practice setting.
5. Coordinates and reviews programs, registers and systems to facilitate quality individual and group health care outcomes.
• Ensures that recall registersare continuously reviewed to achieve optimal outcomes and compliance with all current statutory and regulatory obligations.
• Collaborates with individuals and the primary health team in the development and review of guidelines, protocols or templates
• Participates in practice accreditation processes.
6. Demonstrates proficiency in the use of information management technology and systems to inform clinical care management.
•Understands the funding, billing and business systems used in the general practice
•Participates in practice accreditation processes
•Updates practice and clinical policies and procedures in conjunction with the Practice Manager
•Demonstrates sound understanding of Privacy Act and Confidentiality Regulations.
•Maintains contemporaneous electronic record of clinical interactions with clients and primary care team using BDHC approved clinical software
7. Ensures clinical nursing decisions are communicated to the general practice team.
  1. • Appropriately refers clients to general practitionersand other members of the primary care team
• Collaborates with the primary care team to develop guidelines and protocols
• Attends and contributes to practice and clinical meetings
• Addresses safety and quality issues for individuals and BDHC multi-disciplinary care team
8. Recognises the need for ongoing education and training to maintain competence for nursing practice.
• Adheres toAHPRA registration CPD requirements, self-assessment and peer review to regularly assess and facilitate appropriate ongoing educational & CPD opportunities within the agreed scope of practice
• Identifies the need for updated knowledge base for Clinical practice and liaises with Practice Manager to facilitate attendance at workshops, seminars, conferences and online resources conducive with relevant knowledge acquisition.
• Maintains skills in cardiopulmonary resuscitation and other first aid required in the setting.
Performs other duties conducive to the role as requested by management
REPORTING REQUIREMENTS / Reports any concerns to the Practice Manager
PERFORMANCE APPRAISAL / Initially at 6 month anniversary then annually by Practice Manager unless specific performance management is required

Key Result Area (KRA)

/ Performance Criteria / Monitoring Process/es
  • PROFESSIONAL CONDUCT
/
  • Demonstrates a high standard of personal appearance and conduct, that is: clean, neat, tidy, punctual, and respectful language and manner toward customers, visitors and to each other.
  • Demonstrates sound understanding and implements all relevant Privacy Act and Confidentiality requirements. Information related to a local resident or staff member is at NO TIME discussed with anyone other than the relevant staff member providing service.
  • Demonstrates a flexible, and enthusiastic attitude toward undertaking a variety of tasks with a team approach.
  • Contributes to the efficient and effective management of human and fiscal resources according to
  • the budget
  • At all times promoting BDHC in a positive manner
  • Be actively involved in the orientation of new staff to the working environment.
/
  • Improvement Form System
  • Management Meetings
  • Performance Reviews

  • SAFETY
/
  • Ensure compliance and participates in the risk management/OHS program and contributes to a clean, safe work environment to ensure safety of patients/visitors, other staff/volunteers and self.
  • Reports immediately, any equipment or situation which has the potential to be a safety issue.
  • Participates in problem solving processes to resolve OH&S issues.
/
  • Management Meetings
  • Incident Reporting Process

  • QUALITY IMPROVEMENT
/
  • Provides competent care/service in accordance with the organisation’s documented policies and procedures and legislative requirements relevant to role.
  • Completes a Comments, Compliments, ComplaintsandForm when there is an identified need to improve.
  • Actively participates and contributes to Quality Activities which promote quality improvement to service provided, such as, follow up of Comments / Complaints / compliments forms, meetings, working parties, ongoing education, review of procedures, evaluation of new products and equipment.
  • Regular attendance at clinical, team and organisation meetings as identified by Practice Manager
/
  • Performance Appraisal
  • Improvement Form System
  • Quality Activity Reports
  • Meeting Minutes

  • KNOWLEDGE & SKILLS
/
  • Annual training objectives completed following appraisal to ensure skills and knowledge development to fulfil role and meet Nursing Registration annual requirements. Maintains own knowledge and skills through participation in in-service and continuing education, including; emergency procedures training, reading notice boards regularly, newsletters and memos as distributed.
  • Membership of relevant professional group/s, association/s and or network group (recommendation only).
  • Annual training objectives completed following appraisal to ensure skills and knowledge development to fulfil role.
  • Participate in BDHC mandatorytraining appropriate for relevant position as indicated by Nursing Educator
/
  • Annual Performance Appraisal
  • Attendance Records

  • PROFESSIONAL CARE PRACTICE
/
  • Performs clinical duties within the required level of clinical competency conducive with the RN scope of practice
  • Safe administration of medication according to documented procedures and legislative requirements.
  • Minimum education/training requirement of 30 hours annually or conducive with AHPRA and organisational requirements.
  • Supervises & educates both enrolled and other registered nurses, and students in the Primary Care environment as required
/
  • Improvement Forms, including incident monitoring
  • Internal assessment system
  • Surveys
  • Annual Performance Appraisal
  • Education folder

Coordinators’ Signature: ______Employees’ Signature: ______

Appraisal Review Date: ______

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