Transition Services Coordinator (RN) - Nursing
Vancouver Coastal Health
- Vancouver, BC
- Permanent
- Full-time
- Lead and facilitate acute to community transitions by assessing and evaluating clinical and functional need and coordinating community staff/resources in carrying out the care following discharge from an acute site.
- Be responsible and accountable for the development and effectiveness of policies, procedures and standards for the transition services program in community care.
- Coach and encourage acute and community colleagues to embrace new and evolving clinical pathways and practice (Home is Best).
- Plan and facilitate clinical discussions to support safe client discharges with care teams and other health care professionals; advise on the availability and eligibility for community services.
- Make community referrals based on client needs, urgency and best practices to determine the appropriate treatment; educate and provide consultation to the client/family.
- Coordinate transition of clients to long term care, utilizing clinical decision support tools (Inter-RAI MDS) as appropriate.
- Document and maintain client records and clinical assessments.
- Participate on committees as directed.
- Coordinate care given by others in an area or unit by way of assigning service priority to various Home Health teams and making/adjusting client/patient/resident assignments.
- Assist in administrative activities and optimal use of program resources.
- Current practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives (BCCNM).
- Five (5) years’ recent, related experience which includes three (3) years in a community health setting, one (1) year experience in quality improvement, research and evaluation activities, and a clinical decision-support tool for severity assessment and discharge (Acute/Subacute/SNF/Rehabilitation/Behavioural Health), experience in a tertiary health care environment, or an equivalent combination of education, training and experience.
- Broad knowledge of nursing theory and practice within a client and family centred model of care.
- Broad knowledge of the BCCNM Standards for Nursing Practice.
- Broad knowledge of evidence based nursing practice related to patient acuity and bed utilization practices within a tertiary level teaching hospital.
- Broad knowledge of other health care disciplines and their role in client care and discharge planning.
- Broad knowledge of clinical studies methodology and data presentation.
- Demonstrated ability to apply critical thinking within clinical and evaluation activities.
- Demonstrated ability to work independently.
- Demonstrated ability to work collaboratively as a member of an interdisciplinary team.
- Demonstrated ability to demonstrate, facilitate and coach.
- Demonstrated ability to communicate orally and in writing.
- Demonstrated ability to communicate with, and deal effectively with, co-workers, physicians, other health care staff, clients and their families, and staff of outside agencies.
- Demonstrated ability to effectively deal with conflict situations.
- Demonstrated ability to adjust to new or unexpected events.
- Demonstrated ability to plan, organize and prioritize work.
- Demonstrated physical ability to perform the duties of the position.
- Demonstrated computerized software skills in word processing, databases, spreadsheets, presentations and internet access and ability to operate a computerized patient care information system.
- Ability to operate related equipment.
- Comprehensive health benefits package, including MSP, extended health and dental and municipal pension plan
- Grow your career with employer-paid training and leadership development opportunities
- Wellness supports, including counselling, critical incident and innovative wellness services are available to employees and their immediate families
- Award-winning recognition programs to honour staff, medical staff and volunteers
- Access to exclusive discount offers and deals for VCH staff