This position plays a major clinical and complex care coordination role through the provision of expert clinical assessment, referral and coordination of health and community services for Aboriginal and Torres Strait (ATSI) people with severe chronic disease and complex care requirements living in the community who are at risk of deteriorating health that may result in declining quality of life and a hospital admission.
This position is required to work closely with patients/clients, carers their General Practitioners (GP) and Aboriginal Community Controlled Health Services, to identify needs (medical and non medical), strategies (self management, referrals to specialist services or community agencies etc.) and goals to improve their well being. It is the responsibility of this position to facilitate the implementation and evaluation of this shared care plan with the patients/clients and carers and their GPs.
This position is based at RNSH Aboriginal Health Unit and will work across the Northern Sydney Health District to facilitate appropriate and timely care, support, monitoring and coaching for ATSI people with chronic conditions.