Community Care Nurse- Fraser Canyon Hospital - Agassiz, Canada - Fraser Health

Description

Detailed Overview

Provides care management to frail older adults with complex, acute and chronic conditions and/or adults with ongoing functional impairment in their home, community setting and/or via telephone; establishes and maintains ongoing collaborative partnerships with clients, families, Primary Care Practitioners, Home Health professionals and other community partners to optimize client capabilities and community engagement.

As a member of a multidisciplinary team, provides clinical assessments, coaching, interventions, services and follow up to enable clients and their families to live confidently and safely at home; emphasizes the promotion, maintenance and restoration of health including the treatment of diseases through teaching, counselling and direct client care; facilitates and manages client transitions across the health care continuum to optimize recovery from or adapting to changes in the client's condition to minimize re-admission to residential and/or acute care facilities.

Responsibilities Establishes a therapeutic relationship with the client through the use of interpersonal and interviewing techniques in person and/or over the telephone to ensure the client's choice and autonomy in decision-making and care planning, including the client's right to dignity and privacy.

Using a Care Management approach, collaborates with the client and family to conduct and document an individualized client assessment in person and/or over the telephone; develops an individualized client care/health improvement plan which reflects the client's goals and priorities with an emphasis on self-management; coaches client and/or family to increase their skills and confidence in managing the client's health.

Provides direct client care and identifies other care services required in accordance with applicable guidelines, policies and evidence-based best practice; provides comprehensive explanations of care to the client and family as appropriate.

Initiates and evaluates the appropriateness and effectiveness of the short and long term care plan to meet specific client goals; develops next steps in collaboration with the client and family; develops and supports a transition process for achieving client care goals across the care continuum including discharge and/or transfer to other services, as required.

Accesses system information and resources to review client data such as medical history, progress notes, consultation reports, lab reports and incorporates findings into the care plan; plans, organizes and establishes priorities by using resources effectively and efficiently; responds to unanticipated events and/or changing client or service assignment needs, as needed.

Documents assessments, care provision and client responses according to professional standards and established guidelines including computerized records and databases; maintains related records, documentation and statistics; prepares reports in accordance with established standards and procedures, as required.

Provides health education to the client/family/caregiver to increase their knowledge regarding client's health and to promote/enhance the client's health status by teaching relevant procedures appropriate for care needs; develops relevant informational materials and participates in staff education programs, as required to orient new staff.

Collaborates with members of the multidisciplinary team to ensure effective and consistent client care planning and delivery; ensures care planning information and/or significant clinical changes is communicated to the client, family and members of the multidisciplinary team.

Advocates for system/program changes that will enhance the capacity to support the client/ family/caregiver; demonstrates skills in using a systems perspective to plan, organize and establish priorities and to use resources more effectively and efficiently.

Provides input in the development and revision of standards of care, policies and procedures and advocates for improvements in clinical practice, health care and health care services; participates in the development, implementation and evaluation of quality improvement initiatives within the program by providing recommendations to the Manager.

Maintains a safe environment through adherence to internal and external policies/guidelines/ legislation and reporting through appropriate systems.

Assists with the orientation of clinical and ancillary staff by developing and providing relevant informational material and acting as a mentor and/or preceptor, where appropriate.

Identifies learning goals, maintains and updates current clinical competence and develops competencies and/or knowledge within the designated clinical area of practice.

Performs other related duties as assigned. Qualifications Education and Experience Graduation from an approved school of Nursing.

Two years' recent, related clinical nursing experience working with complex geriatric clients and/or adults with chronic illnesses in a community health setting, or an equivalent combination of education, training and experience.

Current practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives (BCCNM). Valid BC Driver's license and access to personal vehicle for business related purposes, as required.

Skills and Abilities Demonstrated knowledge, skills and competence in the areas of gerontology, geriatrics and adults living with chronic illnesses.

Demonstrated ability to complete initial and ongoing client assessments and provide nursing care through therapeutic interventions. Demonstrated ability to communicate effectively, both verbally and in writing. Knowledge of chronic disease management models. Demonstrated ability to integrate and evaluate pertinent data from multiple sources to problem-solve effectively. Knowledge of broad health care services, community resources agencies and their role in providing a continuum of care. Ability to promote client-focused care including sensitivity to diverse cultures and preferences. Ability to independently manage and prioritize a caseload of diverse clients.

Ability to teach clients and others about topics essential to health care, health promotion and care self management using care management principles.

Demonstrated ability to mentor and act as a preceptor to staff. Ability to work effectively in a dynamic environment with changing priorities. Ability to work independently and as a member of a interdisciplinary team. Ability to operate related equipment including applicable software applications. Physical ability to perform the duties of the position.