Transition Services Coordinator (RN) - Nursing

Vancouver Coastal Health • Vancouver, BC

9d • Onsite

About The Position

The Transition Services Coordinator at Vancouver Coastal Health (VCH) at UBC Hospital in Vancouver, BC, leads and facilitates acute to community transitions. This role involves assessing and evaluating clinical and functional needs, and coordinating community staff/resources for post-discharge care from acute sites. The Coordinator is responsible for developing and ensuring the effectiveness of policies, procedures, and standards for the transition services program in community care. They coach acute and community colleagues on new clinical pathways and practices, such as 'Home is Best'. Key duties include planning and facilitating clinical discussions for safe client discharges, advising on community service availability and eligibility, and making community referrals based on client needs and best practices. The role also involves educating and consulting with clients/families, coordinating transitions to residential care using tools like Inter-RAI MDS, and maintaining client records and clinical assessments. The Coordinator participates in committees, assigns service priority to Home Health teams, adjusts client assignments, and assists with administrative activities and resource optimization. The position is within the Vancouver Community Short Term Assessment and Treatment (STAT) Centre, a community bed-based program for older adults (generally 65+) with physical and/or mental health concerns co-existing with age-related psychological, cognitive, functional, and social needs. The STAT Centre provides comprehensive geriatric and psychiatric assessments, coordinated diagnostic and consultative services, treatment for illness, strategies for coping with disabilities, optimization of physical, functional, social, and nutritional status with the goal of returning home, recreation and activity programming, and collaboration with various health teams to facilitate seamless care transitions.

Requirements

• 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
• Experience with 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
• Ability to operate a computerized patient care information system
• Ability to operate related equipment

Responsibilities

• Lead and facilitate acute to community transitions
• Assess and evaluate clinical and functional need
• Coordinate community staff/resources in carrying out care following discharge from an acute site
• Develop and ensure the 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 client/family
• Coordinate transition of clients to residential 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

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
• Access to exclusive discount offers and deals for VCH staff

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Number of Employees: 501-1,000 employees