JOB AND PERSON SPECIFICATION
TITLE OF POSITION:
ADMINISTRATIVE UNIT:
CDCP Liaison / Telephone Coach
Adelaide Health Service
Classification:
Division: Population & Primary Health
AHP2
Department: Health Service Integration
Classification Reviewed: August 2007
Position No: FM2727
Position Created:
Job and Person Specification Approval
_________________________________________
Delegate
_____/_____/_____
Date
JOB SPECIFICATION
1. SUMMARY OF THE BROAD PURPOSE OF THE POSITION and its responsibilities/duties
CDCP Liaison is accountable to the Program Lead for a significant contribution to the operation,
conduct and delivery of outcomes of the CDCP in the south.
The CDCP is designed to manage avoidable or preventable demand through the growth and
coordination of community primary health care services. The Liaison will work with AHS staff,
external and internal service providers and GP teams in the achievement of the objectives and key
performance criteria and focuses on program liaison functions related to patient screening and
enrolment, service scheduling and progress monitoring. The incumbent will be required to undertake
some limited telephone coaching as a secondary contribution to the program, which will require
specific on the job training. The Liaison is responsible for the complete provision of the intervention
from problem definition and goal setting with the client through to planning, execution and evaluation
of the service provision, under reducing direction from the Program Lead and in line with relevant
professional standards.
The telephone coach component of CDCP uses telephone and mail-outs to deliver regular coaching
sessions to patients occurs after discharge from hospital with a view to facilitate patients with chronic
disease to take ‘ownership’ of their health by empowering them to be ‘driver’ of the process of
achieving and maintaining the target levels for their risk factors while they work in partnership with
their usual doctor(s).
The CDCP targets people at risk of hospitalisation with heart failure and unstable angina, diabetes
and chronic obstructive pulmonary disease in the mild-moderate stages of their disease, who have
the potential to optimise their health status and reduce further hospital admissions. It provides
tailored packages of care over 6-8months including Home Medicines Review, Chronic Disease SelfManagement Programs, Allied Health services, Oral Health Interventions, Telephone Coaching to
manage specific risk factors, Diabetes Group Education and short term goods and services.
Expansion of the program in 2007 will involve:
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The Australian Better Health initiatives for risk factor management and chronic disease self
management services
a cohort of patients with complex needs of the frail aged, characterised by a previous hospital
admission, de-conditioning, mild cognitive impairment, falls and psycho-social, complex
medication management issues, who have difficulty with self management.
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2. REPORTING/WORKING RELATIONSHIPS
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Accountable to the Director of Health Service Integration through the CDCP Program Lead the
incumbent will work individually and as part of the regional CDCP team
Works closely with AHS, internal and external contractors / service providers, GP teams and Sth
Division of GPs.
3. SPECIAL CONDITIONS
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May be required to undertake a health assessment prior to commencement.
Appointment will be subject to a satisfactory Offender History check.
The incumbent may be required to enter into an annual performance agreement for the
achievement of specific outcomes.
Job and Person Specifications are reviewed regularly as part of the ongoing Performance
Development process.
Intrastate and interstate travel may be required.
Must hold a current South Australian driver’s licence and be willing and able to drive.
Some out of hours work may be required.
May be required to work within other locations of the Adelaide Health Service.
4. STATEMENT OF KEY OUTCOMES AND ASSOCIATED ACTIVITIES
Meet the objectives of the Program within the demand management context by contributing
to:
4.1 As a primary role undertake CDCP prescribed Liaison functions at hospital or community
enrolment sites by applying broad clinical skills and service experience in:
 working with staff to identify eligible participants for the program
 undertaking screening interviews with potential participants, enrolling including consenting,
collating multidisciplinary team assessments, setting goals and selecting services with the person
 facilitating communications and planning between the acute sector, the GP teams and other
health providers
 managing a caseload of new and follow up patients through:
 liaising with acute care teams, GPs, CDCP providers and community services to develop
the self management care plan
 processing referrals, and scheduling service components
 organising and facilitation of case conferences (acute teams/ GPs)
 documenting goals, service provision and outcomes
 maintenance of databases
 training for service providers in evidence based practice
 ensuring the CDCP model works efficiently to connect all acute/ GP team/ domiciliary and
community services to ensure tracked patient and information flow, coordination of
services and monitoring.
4.2 Contribute to the continued refinement and use of instruments, tools and methods required for
the cost-effective management of CDCP in the South, such as:
 Early risk identification for patients of the services
 Efficient referral and case search processes
 Risk screening and assessment tools
 Guidelines / protocols, standards or integrated care pathways
 Information and/ or training for patients and carers, service provider and others
 Effective and timely information for GPs and patients/ carers
 Effective lines of communication between acute/ community interface
 Problem definition eg. identification of barriers and risks associated with trialled services
 In consultation ensure appropriate IT specifications are identified and developed
 Recall and monitoring
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Create synergies between telephone coaching and the other service options such as group and
one to one Chronic Disease Self Management (Stanford Lorig or, Flinders University Partners in
Health), Allied Health interventions and GP Care Plans and Team Care Arrangements
4.3 As a secondary and more limited role deliver the telephone coach component of the CDCP using
evidence based protocols and guidelines to perform this function, in addition to increasingly
independent motivational skills, knowledge of the impact of co-morbid disease and experience in
application of self management strategies.
It is executed by applying clinical skills and service experience in:
 working remotely with selected patients on target risk factors related to their chronic disease(s)
and their lifestyle goals via telephone. For example quitting smoking, improving diet, adherence to
diet and medications to reduce blood glucose levels, increasing physical activity.
 undertaking any training or continuing education required to support reaching service standards
related to coaching
 liaising with patients’ GP team and other services as necessary
 assisting patients to develop skills in self management through working on specific risk factor
goals to improve the management of their chronic disease motivate the participant in achieving
these personal goals
 monitoring and measuring individual risk factor and drug adherence outcomes
4.4 Contribute to the completeness of the evaluation by:
 Recording appropriate quantitative and qualitative data collection as per the agreed criteria
 Administering outcome, satisfaction and other tests as required
 Maintaining records of all developments
 Providing information to, and working with key acute and community partners and Clinical
Epidemiology and Health Outcomes and Resource and Clinical Information units to design and
carry out the evaluation plan
 Contribution to the completion of any reports required.
4.5 Provision of concise, clear and accurate information regarding the program operation, outcomes
and its objectives to key stakeholders as required.
4.6 Ensure a commitment to community participation.
4.7 Contribute to ensuring a safe and healthy work environment, free from discrimination.
Acknowledged by Occupant:______________________________ Date:_____/_____/_____
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PERSON SPECIFICATION
1. ESSENTIAL MINIMUM REQUIREMENTS (those characteristics considered absolutely necessary)
Educational/Vocational Qualifications
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For appointment at AHP2 a relevant degree or other qualification approved by the Office for
Public Employment and where relevant, registration with the appropriate professional body.
Personal Abilities/Aptitudes/Skills
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Effective communication skills
Ability to work with a range of people (medical, nursing, AH, pharmacy, data management
personnel, clinical epidemiologists and community program providers) and participants and
carers
Demonstrated problem solving skills
High level of self motivation and decision making skills
Ability to collect and collate data, run focus groups, develop educational material
Ability to work under limited supervision or under broad guidelines and self direct.
Demonstrated capacity to cope with complex and demanding situations
Support for interdisciplinary and inter-sectoral practice
Ability to adapt services to client needs
Service coordination skills
Demonstrated ability to work effectively across the acute/ community continuum in a clinical /
service interdisciplinary team.
Personal philosophy consistent with self management behaviours in patients/ clients
Negotiation skills
Experience
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Health professional (allied health) experience in chronic condition management approaches
Experience or skills in facilitating self-management decisions with clients
Experience in home based health care and / or acute care
Experience in discharge assessment and planning
Experience in acute care transitions to primary health care /community sectors
Knowledge
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Understanding of evidence based practices and principles
Good general knowledge base in target chronic diseases and clinical guidelines
Self management methodologies and applications
Risk factors associated with target chronic diseases
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2. DESIRABLE CHARACTERISTICS (to distinguish between applicants who meet all essential requirements)
Educational/Vocational Qualifications
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Nil stated
Personal Abilities/Aptitudes/Skills
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Ability to use computerised databases
Experience
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Consumer participation
Program evaluation
Working with GP teams
Working in both the Acute and Community sectors of health
Knowledge
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Nil stated
Other details
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Nil stated
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