Role Purpose:

The Care Partner is the designated care manager under the Support at Home Program, responsible for delivering care management activities that enable older people to live safely and independently at home. Working within a rights-based, person-centred framework, the Care Partner collaborates with participants, their supporters, and interdisciplinary teams to coordinate tailored, responsive and inclusive support.
Care Partners function as relationship-based care managers who provide ongoing planning, monitoring, service coordination, and education, with a strong focus on wellness, reablement, and culturally safe care.
They play a key role in planning and overseeing care service delivery across all support streams, including the Assistive Technology and Home Modifications (AT-HM), and work closely with clinically qualified Care Partners when a participant’s needs require advanced clinical input or complex care planning.

What we are looking for:

Care Planning and Coordination
• Collaborate with participants to develop individualised care plans within 28 days of service commencement, ensuring alignment with the Notice of Decision, formal aged care assessment, and approved Support Plan.
• Incorporate the participant’s goals, service preferences, cultural needs, risk factors, and AT-HM requirements.
• Establish and update quarterly budgets, ensuring participants understand their available services and financial responsibilities.

Collaboration with Clinically Qualified Care Partners
• Work as part of a team-based model, escalating care planning and clinical decisions to a clinically qualified Care Partner (e.g., Registered Nurse, Social Worker, Allied Health Professional) where the participant’s needs exceed general care management scope.
• Ensure care plans reflect clinical advice and monitor implementation of recommended clinical interventions (e.g., wound care, mobility equipment, medication support).
Pathway-Specific Coordination
• AT-HM Pathway: Manage service coordination and education related to approved AT or home modifications; support participants with integrating AT into daily routines and safety.
Monitoring, Review and Risk Management
• Review care notes and service delivery data; proactively identify and address emerging risks or changes in participant needs.
• Conduct at least monthly care management activities and schedule formal care plan reviews at least annually or as required by program triggers.
• Support participants to undergo Support Plan Reviews or reassessments via My Aged Care, where appropriate.

Financial and Budget Oversight
• Collaborate with participants to plan and manage individualised budgets in line with their classification and support needs.
• Monitor spending to prevent underspends and overspends and align resource allocation with changing needs, including temporary increases during illness or recovery.
• Liaise with service providers for efficient and appropriate use of resources, especially for AT-HM, clinical, or specialist services.

Relationship Management and Communication
• Build meaningful relationships with participants and their supporters to understand goals, preferences, and life circumstances.
• Communicate effectively with internal and external stakeholders, including GPs, allied health, palliative care providers, and service coordinators.
• Facilitate or participate in case conferences, ensuring care plans reflect shared decision-making and supported risk-taking.

Empowerment and Education
• Promote participant choice and autonomy in service decisions, including supported decision-making and self-management models.
• Provide education on aged care navigation, Assistive Technology use, clinical warning signs, wellness, and health literacy.
• Offer resources and guidance to informal carers and supporters, including during Restorative and End-of-Life pathways.

Documentation and Compliance
• Maintain accurate, timely care notes and ensure documentation supports outcomes under the Strengthened Aged Care Quality Standards, particularly Standard 3 (Care and Services) and Outcome 5.1 (Clinical Governance).
• Ensure care management claims comply with Support at Home business rules, including exclusion of administrative, rostering or travel tasks.
Other tasks as assigned by Coordinator/Manager
• Providing information to prospective consumers about the Support at Home
• Referring prospective consumers to My Aged Care for eligibility assessment
• Referring existing consumers to My Aged Care or ACAS for reassessment when required
• Providing brokerage services including:
o Conducting initial home safety assessment
o Arranging and monitoring services for consumers of service buyers as required
o Responding to requests/ queries from service buyers
o Giving feedback to service buyers as appropriate
• Providing 24-hour on-call service for SaH consumers on a rotating basis with other team members when required
• Assisting the Coordinator with the requirements for accurate statistical data collection
• Assisting the Coordinator in reviewing records, forms, manuals, and working procedures of the program when required
• Be flexible in your approach to work hours to provide relief while other staff are on leave
• Attend staff and team meetings

The above lists are not exhaustive and the role may change to meet the overall objectives of AVWA.