Continuing Care

4 weeks ago

Vancouver, Canada PHSA Full time

**Continuing Care & Discharge Coordinator, Nursing Support Services**

BC Children’s Hospital & SunnyHill Health Centre

Vancouver, BC

**What you’ll do**
- Determine the effectiveness of the program referral and care continuation processes and present recommendations for improvements and system changes to optimize the care continuum, minimize system barriers and ensure timely and appropriate movement through the system. Participate in the implementation of recommended system improvements and quality and safety initiatives.
- Facilitate and coordinate timely intake, reassessments and transitions/discharge by coordinating the continuum of care between the hospital, the community and other external health care facilities and agencies.
- Receive and review all referrals for access and transitions/discharge for the program. Identify suitable services for referral in accordance with established protocols. Work in close collaboration with service providers and health care teams to ensure referral eligibility and needs.
- Collect, analyze and report data for current resource utilization in order to inform system development and work with interprofessional team members by using data to monitor and evaluate improvements in the care continuation process in order to facilitate successful, expedient, efficient, and effective admission and discharge planning.
- Advise and support comprehensive health care team in the assessment, planning, implementation and evaluation of referrals and discharges for children eligible for the program. Work collaboratively with other health care team members to advise and support the direct care nurse to prepare patient specific teaching plans for families of infants and children with complex health care needs.
- Communicate regularly with members of the health care team to anticipate and identify any changes to the upcoming discharge planning needs of the child and their family. Liaise with various community services, agencies and C&W programs in order to advise them of any changes to the care continuation plans of children with complex health care needs and their families.
- Ensure a family centered care approach to the care continuum and discharge planning process, by engaging in partnership with families and advocating for their involvement and collects patient/family input to recommended system improvements.
- In collaboration with the health care team and families, assess the need for and contributes to the development of standardized family education materials and ensure family education materials are current.
- Perform other related duties as assigned.

**What you bring**

Qualifications
- Graduation from an approved School of Nursing with current practicing registration as an RN with the British Columbia College of Nurses and Midwives (BCCNM).
- Three years recent related clinical experience in tertiary pediatric nursing or an equivalent combination of education, training and experience.

You will also have
- Comprehensive knowledge of nursing science theory, and practice within a client and family centred model of care.
- Comprehensive knowledge of the British Columbia College of Nurses and Midwives (BCCNM) standards for Nursing Practice.
- Comprehensive skill and expertise in tertiary pediatric services and related issues.
- Knowledge of relevant policies, procedures, and standards of care.
- Knowledge of other health care disciplines and their role in patient care.
- Ability to put systems in place to address various designated patient population groups, to ensure access to services and facility care.
- Ability to communicate effectively, both orally and in writing.
- Ability to work independently and in collaboration with others.
- Ability to relate effectively to children and their families and others.
- Ability to demonstrate effective CPR techniques.
- Physical ability to perform the duties of the job.
- Ability to operate related equipment including applicable computer software.
- Commitment to develop knowledge and understanding of legislative obligations and provincial commitments found in the foundational documents - including Truth & Reconciliation Commission’s Calls to Action (2015), In Plain Sight (2020), BC's Declaration on the Rights of Indigenous Peoples Act (2019), United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP), Reclaiming Power and Place Missing and Murdered Indigenous Women & Girls Calls for Justice (2019), the Declaration Act Action Plan and Remembering Keegan: A First Nations Case Study - and how they intersect across the health care system.
- Commitment to upholding the shared responsibility of creating lasting and meaningful reconciliation in Canada as per TRC (2015) and BC's Declaration on the Rights of Indigenous Peoples Act (2019).

**What we bring**

Every PHSA employee enables the best possible patient care for our patients and their families. Whether you are providing direct care, conducting research, or making it possi

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