Practive Transformation Coach

PPO Serve is looking for a **Practice Transformation Coaches** to assist patients and clinicians in the projects we support. The Care Coordinator would actively identify and onboard complex patients, facilitating the ongoing care of these patients in an appropriate care setting, in collaboration with the consortium multidisciplinary team, patient, family, and local community services. This requires the building and maintaining of excellent relationships with all levels of healthcare providers and patients. The Care Coordinator is effectively responsible for scheduling, organizing and managing all aspects of a patient’s healthcare maintenance and treatment. Duties include amongst others; helping patients' complete paperwork, communicating with the healthcare team about a patient’s treatment plan and educating patients about resources and options for managing their health.

**YOU MUST BE**:
Proactive, organised, diligent, assertive, an excellent communicator and socially conscious.

**YOU MUST WANT TO**:
Be inquisitive, ask questions, think broadly, and challenge your team mates. Make a difference. Help us to change the health care system using your clinical knowledge and organisational skills. You must want to work in a start-up environment. We work hard, but have fun. If you don’t want to work hard, don’t apply. We are committed and passionate, are you?

**YOU MUST BE ABLE TO**:
Lead, learn quickly, work fast, think big, deliver precisely, iterate, be lean, and prove yourself. Your clinical knowledge must be sound. You must be able to challenge the status quo if it is not working and have the courage to fix it. In addition, you should have a broad range of skills, work hard and smart. You can find answers fast and enjoy the process of building something new. You must be able to work comfortable with all levels of healthcare professionals from social works to nurses to GPs to specialists. You must be comfortable with Word, Excel and learning new systems.

**MANAGE A VALUE CARE TEAM UNIT**:
A. Implement change management strategies in order to improve clinical outcomes, and increase the value delivered for purchasers of health

a. Determine and understand current care delivery status

b. Identify areas of improvement in patient care

c. Develop and implement action plans to actively drive improvements, through proactive discussion and agreement with the internal operational team.

B. Use data to drive discussion and gain support for appropriate interventions and ensure implementation of action plans to improve value of care delivery

a. Determine relevant data requirements

b. Retrieve data from PPO Serve at agreed intervals

c. Analyse and interpret patient data to identify factors requiring improvement

d. Utilise relevant data to achieve MDT meeting objectives

e. Develop action plan(s) as per point (a) above

C. Lead and drive communication with senior management and external stakeholders to accomplish business imperatives and agreed objectives

a. Establish and manage meeting schedules, content and outcomes (including MDTs, ad-hoc management/operational meetings, Director/shareholder meetings and others as required)

b. Maintain accurate recordkeeping and provide ongoing feedback

c. Ensure consistent discussion and review of items as per (a) and (b) above

d. Ensure regular and updated communication amongst all relevant stakeholders

e. Provide regular management reporting on TVCT unit performance (clinical, contractual, financial, operational)

D. Lead and manage care coordination and MDT meetings to achieve specific TVCT objectives

a. Ensure that all factors as per points (a) to (g) above are tabled, discussed, agreed and implemented

b. Monitor and manage care coordination implementation and reporting

E. Drive and maintain relationships with other health care professionals required within the multidisciplinary team (including care coordinators, allied professionals, care service partners and PPO Serve)

a. Establish and manage ongoing feedback meetings

b. Lead and drive care coordinator monitoring, actioning and reporting

c. Monitor and evaluate care outcomes changes relative to points (a) and (b)

d. Manage contractual requirements and outcomes with relevant service providers and internal parties

F. Establish and maintain relationships with community and social service agencies

a. Ensure current and accurate records of available referral resources (including allieds, community counselling and support entities, social support groups etc)

b. Identify how these parties can be integrated into the action plans to maximise patient care improvements and patient referral value

G. Maintain operational standards: track and report on progress and compliance of all required actions and agreed undertakings between the TVCT unit and other parties

a. Understand relevant stakeholders’ obligations within the Value Contract

b. Lead and drive co-operative practices to ensure compliance and achievem