Nurse Care Coordinator

As a primary care AOD care coordinator you will support GPs, practice staff and pharmacists who provide care to people with significant AOD issues. The project aims to encourage primary care staff to provide services to AOD clients (for general health care and / or AOD care) and with coordinator support, to take on new clients with AOD issues. Managing the client group in primary care helps to reduce potential ED presentations and hospital admissions.

The complex care needs of many AOD clients can be beyond the scope of practice staff and it is anticipated that the coordinator will help clients to follow up with health and social needs as identified by GPs and outlined in a GP management plan. This will ensure the client has health and social needs met and maintain their management in primary care. This may involve liaison with GPs, specialists, acute services, community heath, NGOs and social services that facilitates multidisciplinary care.

The coordinator will also liaise with pharmacists providing AOD services and promote the NSW Health Pharmacist administered Buprenorphine scheme. They will support practices and pharmacies with education and service information and promote uptake of further AOD training opportunities to increase the capacity of local primary care providers. The coordinator may assist GP practices in more detailed AOD assessment, care planning, attend practice appointments, monitor client progress and report back on outcomes. The coordinator may provide brief interventions or health coaching and recommend referral to AOD treatment providers as required. The Primary Care AOD Care Coordination project aims to demonstrate that with support of an RN Care coordinator, AOD clients may be effectively and appropriately managed in primary care settings.

Duties and Responsibilities

• Offer a care coordination and navigation program to GPs and their clients with AOD issues.
• Support GPs in opioid replacement treatment prescribing, increase the number of those trained to prescribe and those without training (but prescribing for up to 5 clients).
• Support pharmacists who provide services to AOD clients.
• Promote the NSW Health pharmacist administered depot buprenorphine program.
  ensures that a suitable GP management plan is developed for all referred clients:
  • which will help guide the support the Primary Care AOD Care Coordinator will provide to the client;
  • attends practice appointments for care planning purposes and GP/client support and assist practices with Medicare Benefit Schedule care plans (chronic disease and/or mental health);
  • provides a referral outcome report to referring GPs via secure messaging through the secure messaging platform provided by WHL;
  • coordinates care for people with significant AOD issues that is beyond the scope or timeframe of the referring GP’s capacity by providing service navigation, care coordination, referral, linkage, and psychosocial support to assist compliance with care planning and care delivery;
  • works with referred individuals to connect them to the most appropriate services through a holistic client centred approach;
  • follows up with clients to encourage and monitor attendance of required and recommended care;
  • provides brief interventions and health coaching where appropriate;
    regularly reviews the client progress against their care plan and encourage a GP review if health/ AOD issues deteriorate;
  • engages with relevant pharmacies to promote the pharmacist administered depot buprenorphine program to GPs/ practices and pharmacies;
  • supports practices and pharmacies that provide services to clients with AOD issues with education and service information and promote uptake of further training opportunities;
  • promotes the WHL AOD Health Pathways to GPs and relevant practice staff;
    supports PHN initiated AOD capacity building and training activities for general practices and pharmacies;
  • document and report to WHL on any additional identified AOD training needs for primary care providers; and
  • develops and implements appropriately tailored evaluation survey tools to gauge health professional and client feedback on the efficacy and impact of the services delivered
• Ensure the effective communication with other members of the multidisciplinary team, clients and visitors and provide consultation and liaison to government, non-government and private practice in coordinating client care across all LLW sites and Health Districts.
• Work collaboratively and effectively within a multidisciplinary team by effectively integrating the profession specific perspective, to affect optimal health outcomes for consumers.
• Engage in varied and complex inter-sectoral linking and liaison with relevant stakeholders and partnerships, including communication and interpretation of complex clinical information to secure the service needs of consumers.

Details

Qualifications

• Registration as a Registered Nurse as a Registered Nurse with AHPRA with a current annual practicing certificate is mandatory for this position
• 2 years experience working in AOD services
• Experience working in community and / or primary care

Essential Criteria

• Demonstrated skills in managing clients with complex care needs (physical and social)
• High level communication skills and demonstrated ability to managing challenging behaviours
• Previous experience in care coordination/ service navigation/ case management
• Capacity to work independently as well within team care processes
• Experience in providing or facilitating AOD education for health professionals
• Demonstrated expert knowledge and extended practice in the application of evidenced based clinical management, diagnostic investigation and pharmacological management of clients with alcohol and drug issues within an acute and community health care setting.
• Demonstrated high level communication and interpersonal skills including the ability to consult, liaise and negotiate with hospital and community health providers, General Practitioners, community agencies and non-government organisations to sustain health outcomes for people in the community

How to Apply

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Lives Lived Well

At Lives Lived Well, we’ve been treating and supporting people whose lives are affected by alcohol and other drugs for over 50 years. We also support people with mental health and gambling concerns and those transitioning from correctional centres. We’re growing fast and building a reputation as a trusted, innovative provider, focused on clinical excellence… and we’d love you to be part of it.

If you have compassion, the ability to work without judgment and share our belief in recovery, then join us and open up your career in human services.