Undertake a comprehensive assessment of patients, including those with diverse or complex healthcare needs.
Formulate and deliver an individualised treatment programme based on evidence based practice and treatment options, using assessment, reasoning skills and knowledge of various treatment/care?models.
Ensure appropriate referral of patients to other professionals and services using established protocols and pathways.
Coordinates and maintains a caseload
Conducts case management services for individuals age 60+ and assist them in accessing resources in the community.
Meet with older adults in various settings, (such as the hospital and client?s home), referred by DHA and other referral sources.
Provides advocacy, information and assistance, and act as liaison with other social service agencies that provide services for older adults
Meets with family members, caregivers and client to determine the best setting for clients, and the level of care needed to maintain independence.
Maintains program statistics including entering of client demographics, care plan, services provided outcomes and billable hours.
Keeping case note records and knowledge of participants, maintain an awareness of participants? needs and connect them to appropriate services.
Maintain client follow up to ensure patients receive adequate services.
Assist the team in establishing attainable goals to maintain stability.
Maintains program statistics including: entering of client demographics, care plan, services provided outcomes and billable hours.
Maintains confidentiality of client information at all times.
Prepares and completes required reports within required period.
