Clinically responsible to: Urban Team Leader

Professionally accountable to: Director of Nursing and Clinical Services

Purpose of the position

The aim of the position is to coordinate care for patients and whānau with specialist palliative care needs in the community, through: 

• Utilise professional knowledge, and skill to ensure provision of services to meet specialist palliative care requirements 
• Act as a point of contact for patients and whānau
• Undertake comprehensive assessment. 
• Develop, implement and evaluate care plans in line with patient and whānau goals, to optimise quality of life 
• Participate as an integral member of the inter-disciplinary team, in assessing, and planning care, for patients and whānau
• Facilitate continuity of care and services, by liaising with all services and disciplines, relevant to the patient’s care. To enhance service delivery and reduce duplication 
• Utilise clinical assessment skills, and professional knowledge, based on scientific research, and recognised  best practice 

Functional relationships

• Patients and Whānau
• OCH Staff
• Primary Palliative Care providers 
• Health Authority Providers
• Relevant Government Agencies
• Relevant Community Organisations
• OCH Education Service
• Aged Residential Care Providers 

Specific areas of responsibility

1.    Provides Clinical Care Coordination

• Undertake first and ongoing assessment in an organised and systematic way, using appropriate tools and best methods to assist the collection of information. Apply skills and knowledge to appropriately determine specialist palliative care needs, then anticipate and plan care, in negotiation with patient, their whānau, and the wider interdisciplinary team  
• Advocate where necessary to ensure that the highest standard of care is provided to patients and whānau
• Act as the link person between generalist palliative care providers, and other healthcare providers, to maximize quality of life
• Identify goals of care with the patient and whānau, supporting them to achieve these
• Coordinate services, ensuring provision of supports enabling the person to remain in their home, if that is their wish 
• Make timely and appropriate referrals to facilitate patient and whānau care
• Respond appropriately to emerging situations, ensuring patients and whānau have the resources and/or information required. Seek assistance from line managers in complex situations
• Following all interactions, ensure information is updated as per the organisational expectations, and that information is completed accurately in a timely manner 
• Develop and maintain effective relationships, acting as a resource for health professionals, providers, and agencies regarding specialist palliative care 
• Practice in a way that respects the identity of patients, whānau and their right to hold personal beliefs, values and goals, providing a culturally appropriate and culturally safe service, maintaining an effective multicultural perspective whilst recognising and honouring the principles of the Te Tiriti O Waitangi  
• Participate in an extended care roster, in order to provide palliative care to community patients with complex needs, in their homes

2.    Education and training 

• Provide education to patients and whanau to ensure provision of safe holistic care 
• Participate in the OCH education program
• Participate in on-going development of OCH policies and processes as requested 
• Provide support to line managers as requested, ensuring staff, volunteers, visitors and students are provided with a comprehensive explanation of OCH services
• Act as a resource, or conduit to resources, for generalist health providers 
• Support relevant research and education undertaken by individuals/teams

3.    Self-management

• Attend to own professional and governing body requirements 
• Identify own learning and development needs, take responsibility for seeking out and participating in training opportunities, requesting support where required
• Prioritise time and work effectively 
• Fully participate in the OCH appraisal process
• Utilise effective self-care including professional supervision
• Complete all OCH mandatory training and education requirements 
• Maintain a PDRP portfolio 
• Demonstrate and practice effective personal self-awareness identify potential risk to self, others or the organisation, manage or/and reduce risk 

4.    Compliance / Quality / Audit / Risk 

• Practice within professional standards, code of conduct, professional ethics and scope of practice. Provide culturally appropriate care at all times
• Comply at all times with OCH policies and procedures and take responsibility for own actions/inactions(if these conflict, seek advice from the line manager) 
• Be familiar with, promote and ensure compliance with OCH quality, health and safety, and infection prevention and control policies
• Maintain an active role in OCH quality improvement programme
• Promote Hospice New Zealand standards and quality initiatives
• Participate in audits and research that are evaluating aspects of the service, including collecting statistics about activities and outcomes
• Contribute, as requested, to the development of periodic reports on service operations
• Demonstrate an understanding of risk, identifying emerging risks and ensuring prompt reporting of risk. Participate in the development and follow through of risk mitigation action plans.
• Identify, take appropriate action and promptly report all incidents, accidents and/or near misses and security incidents. 

5.    Communication and team work

• Collaborate with other members of the interdisciplinary team, both internal and external 
• Role model OCH values and ensure these values are reflected in all actions and behaviour
• Role model good communication 
• Participate in team planning as required
• Attend and participate in meetings as required
• Provide accurate, timely and concise written documentation and spoken information to leaders, colleagues, other healthcare providers, patients and whānau
• Participate in ongoing development of palliative care services, including provision of education and promotion of OCH service

Updated: 19 June 2023