Carers ACT will be working alongside ACT Health to facilitate the smooth transition of patients from acute care settings, including Canberra Hospital, North Canberra Hospital, and University of Canberra Hospital, to community settings, including their own homes. This program offers short-term, non-clinical support through a brokered model, ensuring a safe and prompt discharge process. This role involves working on-site in the hospitals as well as in the office.

If successful, you will be:

-Engaging in hospital discharge and bed management meetings with participants, their care teams, and families or carers.

-Conducting participant intake, perform needs assessments, and identify discharge goals.

-Developing discharge care plans, outlining necessary non-clinical services for safe transition home or to a designated community setting, such as domestic assistance, personal care, meals, transport, and bridging supports.

-Coordinating and arrange services from CATS and Carers ACT approved providers for up to 6 weeks, including accessible transport from hospital to home or community setting.

-Monitoring Participant progress and adjust services to meet changing needs.

-Facilitating connections to longer-term assistance, including other CATS Service providers or community care providers and supporting access to NDIS or My Aged Care services.