Hospice Clinical Navigator - Cobourg, Canada - Community Care Northumberland

Description

Reporting to the Community Manager, the Clinical Navigator is a member of the interdisciplinary team responsible for coordinating and navigating both clinical and supportive care for clients with a life limiting illness and their families.

The Navigator collaborates with primary care providers and other community services in the implementation of shared-care plans through the provision of assessment, referral and access to palliative care and grief support services.

• Provides personcentered care; ensuring shared care team is aware of need for and meaning of a personcentered approach.
• Provides leadership and influences clinical standardsetting, quality improvement and change management, facilitating the development and implementation of care pathways.
• Performs formal, standardized holistic clinical assessment and intervention, assessing client and family needs in assigned jurisdictions.
• Connects and coordinates care and service for clients and families, providing information, support and guidance in decisionmaking including grief and bereavement followup.
• Works with client, family, hospital, and community providers to facilitate transitions of care and service supports across multiple settings of care (i.e. hospital, retirement home)
• Participate in 24/7 oncall team coverage rotation.

• Documents, tracks and prioritizes care requests to ensure all clients/families receive timely response, including followup calls to clients/families to ensure care needs are being and have been met.
• Completes regular and timely documentation and statistical records.
• Manages client files, ensuring information is up to date at all times
• Assist with and attends clinical rounds meetings.
• Notify team members and updating files when situations change including the death of a client to ensure bereavement services are in place.
• Adheres to all statistical collection and reporting system requirements of the organization and funders.

• Collaborates with health partners to develop a plan of care for transitioning clients with an advanced lifethreatening illness into community palliative care
• Collaborates and communicates through formal and informal case conferencing with health providers and the shared care team to determine appropriate strategies to achieve client focused outcomes.
• Assists in the coordination, prioritization and navigation of all incoming calls to internal and external community resources, including sharing information, scheduling initial home visits, providing guidance/direction to community resources, ensuring team members are up to date on client and family care at all times
• Liaise with Home and Community Care, community agencies, clinics, pharmacies, primary care and more with regards to reports and service requests
• Provides for a culture of sharing, openness, education and mentoring to other team members and nonpalliative trained professionals, students and volunteers.
• Facilitates an environment and attitude where values and beliefs regarding shared care coordination are clearly articulated.
• Works with partners in the need identification and delivery of palliative care education.
• Promotes the philosophy and goals of the agency both locally and throughout the County, developing and maintaining a liaison with other community support services.
• Commits to meeting the privacy obligations and requirements of the agency as a custodian of Personal Health Information.
• Actively participates and complies with the Health & Safety Program of the agency.
• Promotes the philosophy and goals of the agency both locally and throughout the County.
• Contributes to team effectiveness and agency success.

• Registered Nurse with CNA and Advanced Practice Certification(s) in palliative care
• Minimum of five (5) years recent experience in hospice palliative care
• Minimum of five (5) years of community nursing experience
• Experience in a leadership, administration, and care coordination role
• Demonstrates respectful, courteous, caring attitude in all interactions.
• Solid experience in care planning and communicating with multiple providers.
• Proven history of working well within an interdisciplinary team with excellent interpersonal skills
• Critical thinking and problem solving skills.
• Proven leadership abilities with effective verbal, nonverbal and oral communication skills
• Administrative skills with computer proficiency and accuracy for all documentation and record keeping, and attention to detail.
• Valid driver's license and ability to travel throughout Northumberland County for home visits and meetings.
• Adheres to all standards, practices, policies and procedures regarding privacy and confidentiality of information, and ethical practices as set forth by employer and regulating College.
• Other skills include conflict management and problemsolving skills where