Purpose of Position
Staff working within the AARCS model will target early and appropriate identification of discharge support needs of older people admitted to hospital who have multiple health and care needs that put them primarily at risk of, or in need of residential aged care directly from hospital.
They will identify, plan and facilitate an older person’s care after hospital along with monitoring the person’s presenting problem and acute care intervention using a case management model across the continuum of care.
AARCS will take the lead role in facilitating the patient’s access to an aged care place on discharge.
The key expected outcome is to maximise efficiency and effectiveness for older people with complex needs requiring access to Australian Government funded aged care place or alternate service. AARCS uses a patient-centred process that provides coordinated timely identification, holistic assessment, care recommendation and facilitation through the hospital system. AARCS discharge planning/case management services for the older person will help to eliminate unnecessary delays in the transfer of care of older patients, thus reducing the number of patients having prolonged and potentially unsafe hospital stays.
Discharge Planning Liaison Nurse - Registered Nurse
Permanent full / part time
Monday - Friday
• Current registration with AHPRA as a Registered Nurse
•Extensive clinical skills in aged care including community and hospital based experience, ability to lead family/case conferences and to facilitate coordinated and timely discharge planning.
•Ability to undertake comprehensive and holistic assessments to plan care for older people in conjunction with acute care multi disciplinary services and other Aged Care health services
•Case management and liaison skills and ability to work with patients, families and aged care providers external to the hospital setting, including ability to develop and maintain formal links with local ASET services, ACAT Placement services (where these exist) and ACAT Delegates.
•Sound knowledge of the health care and functional support needs of older people and their carers in the hospital, community and residential care settings.
•Knowledge of the Guardianship Tribunal, Office of the Protective Commissioner and Australian Government Guidelines for the Aged Care Assessment Program specifically in regard to eligibility requirements, client consent and approval for entry to an Aged Care place (including the associated clients c
•Demonstrate ability to prioritise and manage own workload, collect data for the target group and service delivery parameters, and meet benchmark response times.
•Demonstrated Computer literacy