Care Management Transition Leader (CMTL)

Vancouver Coastal Health • North Vancouver, BC

13d • CA$49 - CA$63 • Onsite

About The Position

Within the context of a patient and family-centred framework and continuum-based care model and in accordance with established standards of professional practice and the vision, values and policies of the organization, the Care Management Transition Leader (CMTL) facilitates patient’s care management and transition planning across the care continuum from admission through discharge. Coordinates and collaborates with the acute interprofessional team to expedite effective patient care and coordinates timely sustainable discharge plans. Conducts comprehensive nursing assessments, directs the interprofessional team on appropriate level of care and determines sustainable, quality discharge plans. Assesses and evaluates the clinical and functional status of the patient by coordinating both acute and community staff and resources to ensure the timely and safe discharge of patients. Plans and facilitates clinical discussions to support timely and safe patient discharges with care teams and other health care professionals by advising on availability and eligibility of community resources. Accountable for the development and effectiveness of policies, procedures and standards to support care management and discharge planning. Intervenes to address barriers and provides leadership to achieve optimal outcomes including securing funding and approvals for services as required. Ensures relevant assessments are completed to determine the appropriate treatment and make community referrals based on patient care needs and urgency. Provides education and consultation to the patient/family and coordinates the transition of the patient post acute care. This work is framed within VCH’s commitments to our pillars of Indigenous Cultural Safety, Anti-Racism, Equity, Diversity and Inclusion, and Planetary Health.

Requirements

• Current practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives (BCCNM).
• Three (3) years’ recent, related clinical nursing experience across the care continuum (i.e. acute/community) including (1) year experience in a supervisory/leadership role responsible for patient care coordination, access and planning, case management and/or discharge planning, or an equivalent combination of education, training, and experience.
• Comprehensive knowledge of Nursing theory and practice within a patient/family centered model of care across the care continuum.
• Comprehensive knowledge of the BCCNM standards for nursing practice.
• Broad knowledge of evidence-based nursing practice related to various patient population groups, acute and community care areas, and demonstrated ability to apply knowledge to a case management process.
• Broad knowledge of pathophysiology and pharmacology and demonstrated ability to apply knowledge to safely plan transition/discharge.
• Broad knowledge of biological and pathophysiology indicators related to severity of illness to apply medical appropriateness criteria to resource utilization and transition/discharge planning.
• Broad knowledge of the illness or disease process and potential long-term complications.
• Broad knowledge of other health care disciplines and their roles in patient care.
• Broad knowledge of clinical pathways, expected length of stays, resource utilization, and patient assessment.
• Broad knowledge of external agencies and community resources.
• Demonstrated ability to engage in comprehensive assessment, observation and monitoring of patients.
• Demonstrated ability to plan, organize, and prioritize work in relation to unit and hospital access and flow needs.
• Demonstrated ability to analyze situations, problem solve, deal with conflict and negotiate resolutions in a timely manner.
• General knowledge of Trauma Informed Practice and Harm Reduction approaches and Strengths-based care.
• Demonstrated ability to promote Indigenous Cultural Safety.
• Demonstrated ability to provide competent and culturally safe care in a variety of settings and with diverse populations.
• Demonstrated ability to provide leadership, work direction and consultation.
• Demonstrated ability to work independently and as a member of an interprofessional team.
• Demonstrated ability to develop and maintain collaborative working relationships and communicate (verbally and in writing) effectively with patients and their families, coworkers, physicians, other health care staff, and staff of external agencies.
• Demonstrated skill in CPR Techniques.
• Ability to operate related equipment including applicable software applications.
• Demonstrated physical ability to perform the duties of the position.

Responsibilities

• Facilitates patient’s care management and transition planning across the care continuum from admission through discharge.
• Coordinates and collaborates with the acute interprofessional team to expedite effective patient care and coordinates timely sustainable discharge plans.
• Conducts comprehensive nursing assessments, directs the interprofessional team on appropriate level of care and determines sustainable, quality discharge plans.
• Assesses and evaluates the clinical and functional status of the patient by coordinating both acute and community staff and resources to ensure the timely and safe discharge of patients.
• Plans and facilitates clinical discussions to support timely and safe patient discharges with care teams and other health care professionals by advising on availability and eligibility of community resources.
• Accountable for the development and effectiveness of policies, procedures and standards to support care management and discharge planning.
• Intervenes to address barriers and provides leadership to achieve optimal outcomes including securing funding and approvals for services as required.
• Ensures relevant assessments are completed to determine the appropriate treatment and make community referrals based on patient care needs and urgency.
• Provides education and consultation to the patient/family and coordinates the transition of the patient post acute care.

Benefits

• Comprehensive health benefits package, including MSP, extended health and dental and municipal pension plan
• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level