Position overview

The Liaison and Navigation Service (LaNS) provides liaison, navigation, care coordination and complex case management for people with complex health and psychosocial needs.

LaNS improves a consumer’s experience and their health outcomes through information sharing, integration of care across primary, secondary, and tertiary services, and coordination across health and community services. It focuses on the provision of the right care, at the right time, at the right place, by the most appropriate provider in partnership with the consumer and their care supports. This includes a focus on providing care outside the acute setting with outreach to clients in the ACT community.

The service is comprised of a multidisciplinary team that assists consumers and their supports to navigate the multiple services involved in their care. The service provides and supports patient-centred, trauma-informed, strengths-based, integrated, and coordinated care. It works closely with acute and community services, and across health and psychosocial services, to reduce the challenges consumers and their supports face when required to access multiple services, to ensure the highest quality of care.

The Care Navigator will undertake assessment from an interdisciplinary perspective and coordinate treatment/therapies and psychosocial supports to ensure the facilitation of timely and safe access. The role will work with consumers and their care supports to provide case management, system navigation, advocacy, support, and connection with appropriate services. It will champion person-centred care and actively promote the needs of consumers for navigational support.

This unique role is an opportunity to build relationships with consumers and their supports, GPs, diverse acute and community services, and external agencies, to anticipate and reduce the challenges that people with complex health and psychosocial needs, and their supports, can face. It is an opportunity to ensure the highest quality of care, information and support is provided when consumers and their supports need it, to optimise their health and wellbeing and assist them to navigate the complexities of their care.

The role will be a point of coordination with external health and human services, and work with CHS services and current specialty care coordinators to support consumers and improve the formal networks and pathways for information sharing, coordination, and ED avoidance.

The Care Navigator will work to develop the clinical scope of the role with the intention to undertake practical clinical support and interventions to support consumers to stay well in the community, and to work directly with outpatient and community services to minimise the need for acute care presentation.

The Care Navigator will also take on a key role in the ongoing review and development of the service, working collaboratively with colleagues, consumers, and external agencies to contribute to and guide the ongoing co-design of this innovative patient-centred service.

As a member of the LaNS team, you will remain committed to, and focused on:

• Placing people with complex health and psychosocial needs, and their families, at the centre of their own care,
• Involving the consumer and their supports in care planning,
• Anticipating and removing barriers to care,
• Assisting consumers and their supports to make sustainable connections to the services and supports they need,
• Helping to solve problems, coordinate care, and improve the flow of information between the care team and the consumer and their supports,
• Listening to consumers and their supports and acknowledging that they are experts in their own health.

Key Responsibilities

Specific responsibilities include, but are not limited to, the following:

1. Provide a high level of skilled clinical care through assessment, planning and implementation of care, in accordance with Canberra Health Services policies, procedures and clinical guidelines.
2. Actively contribute in area of clinical expertise to the development and implementation of clinical pathways/protocols for Allied Health led interventions to assist in ED avoidance.
3. Using high-level communication skills and an understanding of the social determinants of health, work with consumers and their supports to identify and engage appropriate internal and external services to provide effective ongoing integrated care.
4. Work with general practice, community services, outpatient departments, and other services to build on and lead the formalisation of the coordination and sharing of clinical information to improve continuity of care across health and social services.
5. Actively participate in quality improvement and research activities in relation to the continuity and coordination of shared care for consumers.
6. Support and promote the CHS values of Reliable, Progressive, Respectful and Kind through a working understanding of the integral role these values play in the care of consumers with chronic and complex health care needs.
7. Actively participate in supervision, continuing professional development and performance management.
8. Undertake other duties as directed, within the approved scope of clinical practice, ensuring the delivery of high-quality, trauma-informed, person- and family-centred, safe, and best-practice patient care.
9. Undertake other duties appropriate to this classification level that support the effective operation of the organization.

Competencies

Specific responsibilities include but are not limited to the following.

Person-centred care

• Ability to provide and advocate for holistic, trauma-informed, and strengths-based care.
• Ability to identify and address barriers to healthcare for individuals with complex needs.

Leadership

• Ability to assess situations, make decisions, and solve problems with sound judgement.
• Advocacy skills with a sensitive and curious approach to complex situations.

Communication

• Ability to actively listen, establish trust and rapport, and build collaborative relationships.
• Ability to convey complex information verbally and in writing to support patients, families and treating teams to navigate systems.

Organisation

• Strong organisation and time management skills with proactiveness and flexibility.
• Ability to manage competing priorities in a calm and efficient manner in a fast-paced and changing environment with a high degree of autonomy.

Cultural competence

• Strong understanding of, and adherence to, culturally safe and sensitive practice.
• Ability to meet the needs of culturally diverse and vulnerable populations.

Continuous learning and improvement

• Critical thinking and self-reflection, including ability to participate in professional supervision.
• Ability to review, evaluate and improve systems and processes.

Interdisciplinary collaboration

• Ability to work effectively with multidisciplinary teams.
• High level of skill in coordinating care with a range of service providers.

Proficiency with technology

• Proficiency with electronic patient management systems and strong adherence to efficient workflows.
• High level of attention to detail and skill in electronic documentation and information retrieval.

Knowledge of healthcare systems

• Ability to navigate health and psychosocial services across hospital, community and primary care settings.
• Ability to build links and collaborate with a range of health and psychosocial services

Qualifications

Essential

• Hold an undergraduate or postgraduate qualification in a relevant Allied Health profession or relevant experience.
• Hold a current Driver’s Licence and be willing to travel to meet clients and stakeholders in the ACT community.

For Psychologists:

• Be registered or be eligible for general registration with Psychology Board of Australia.

For Occupational Therapists:

• Be registered or eligible for registration with Occupational Therapy Board of Australia
• Eligibility for professional membership of Occupational Therapy Australia.

For Social Workers:

• Degree in Social Work
• Eligibility for membership of the Australian Association of Social Workers
• Registration or eligibility for registration under the Working with Vulnerable People Act 2011.

Desirable

• Have an understanding of how the National Safety and Quality Health Service (NSQHS) indicators align with this role.

Experience

Essential

• Substantial clinical experience in the acute, sub-acute, community and/or primary health setting of greater than 3 years.

Desirable

• Clinical experience within professional field working with people with complex health care needs.
• Experience providing or coordinating care across acute, community and/or primary care settings.
• Experience working with individuals who experience mental illness/mental disorder and insight into their needs, experiences and outcomes when accessing health services.
• Experience which provides insight into the consumer perspectives of managing complex ongoing healthcare.
• Primary health assessment and treatment experience.
• Experience or knowledge of the CHS Exceptional Care Framework, and all other related frameworks.

Prior to commencement

Appointment to this position is conditional on being granted and retaining appropriate clearances:

• Pre-employment National Police Check.
• Current registration issued under the Working with Vulnerable People (Background Checking) Act 2011 is required.
• Comply with Canberra Health Services Occupational Assessment, Screening and Vaccination policy.
• Comply with CHS credentialing and scope of clinical practice requirements for allied health professionals.

Important information

All employees are required to:

• Adhere to the Canberra Health Services Values and the ACT Public Service Code of Conduct.
• Act in accordance and comply with all relevant Safety and Quality policies and procedures.
• Comply with all relevant clinical and/or competency standards.

CHS is leading the drive to digitally transform health service delivery in Australia through the implementation of a territory wide Digital Health Record. Computer literacy skills are required which are relevant to this role as you will be responsible for completing required documentation and becoming a proficient user of the Digital Health Record and/or other Information Technology systems; once proficient, you will need to remain current with changes, updates, and contingencies.

What you Require (Key Selection Criteria)

These are the key selection criteria for how you will be assessed in conjunction with your resumé and experience.

1. Demonstrated high level knowledge, practice and competence in providing effective and safe clinical care and management to people with complex health and/or psychosocial care needs. With a demonstrated understanding of the specific challenges they experience when accessing health services.
2. Demonstrated ability to participate in the initiation, implementation, embedding and evaluation of strategies, systems, and processes to optimise evidence-based practice and/or improve healthcare for people with complex health care needs.
3. Evidence of critical self-reflection, commitment to professional development, active participation in mentorship and education of others, and participation in quality improvement and research activities that contribute to improved healthcare for people with complex health care needs.
4. Demonstrated high-level interpersonal and communication skills using a person-centred approach, with proven ability to work within an interdisciplinary team and develop positive working relationships with patients and families and a broad range of professional disciplines.
5. Demonstrates understanding of, and adherence to, safety and quality standards, Work Health and Safety and the positive patient experience. Displays behaviour consistent with CHS’s values of reliable, progressive, respectful, and kind.

Work environment description

The following work environment description outlines the inherent requirements of the role and indicates how frequently each of these requirements would need to be performed. Please note that the ACT Public Service is committed to providing reasonable adjustments and ensuring all individuals have equal opportunities in the workplace.