Clinical Lead, Medical Home Team

6 months ago

Calgary, Canada South Calgary Primary Care Network Full time

**Status**: Full-time, Permanent

**Schedule**: Monday - Friday. Occasional overtime, evenings and weekends may be required

**Location**: Primary Care Network Wellness Centre at #4000, 1800 194 Avenue SE; Calgary, AB

Eligible for hybrid remote work

**Reports to**: Program Manager, Medical Home

**Position Summary**

In collaboration with the Clinical Supervisor and Program Manager, the Medical Home Clinical Lead provides oversight and support to the Medical Home clinical team with regard to direct patient care, medical home relations, clinical program development and service delivery. The Clinical Lead supports, educates and advises the clinical team in adherence to evidence based clinical interventions, Primary Care Behavioural Health Provider (PCBH) services and primary care best practice methodologies in member clinics (The Patients Medical Home). A collaborative working relationship with SCPCN Clinical Services teams is essential to the success of this role.

**What Does the Role Do?**

Clinical Leadership and Education (50%)
- Assists in the planning, development, implementation and evaluation of Patients Medical Home principles in collaboration with the Medical Home team.
- Conducts regular site visits to medical home clinics to support PCBH provider integration, establishment and maintenance of referral flows and systems and optimization of PCBH provider/Medical Home Clinical services.
- Provides consultation to medical home team and Practice Facilitation team to identify medical home implementation and operational efficiencies at the clinic level.
- Identifies and supports the coordination of educational opportunities to meet the needs of the Medical Home team, building capacity within the Medical Home.
- Assists in coordinating transitions with PCBH providers in Medical Home clinics due to attrition, absences, “fit” or general Medical Home changes.
- Works in collaboration with PCBH Providers, SCPCN Practice Facilitators and Medical Home clinic level designates to develop panel identification strategies to detect patients “at risk” for physical or psychological deterioration and recommends clinical best practice methodologies and interventions suited to those populations of patients.
- Assists Clinical Supervisor and Program Manager in establishing and maintaining standards of care in the Medical Home with respect to documentation, assessment, best practice guidelines, clinical practice guidelines and informs performance evaluation within the medical home team as needed.
- Supports Clinical Supervisor and Program Manager in the coordination and orientation of new PCBH providers as well as ongoing training of clinicians in relevant biopsychosocial techniques.

Patient Care (40%)
- Interviews and assesses the biopsychosocial aspects of health and well-being of patients in primary care.
- Provides behavioral/biopsychosocial interventions to patients in primary care in collaboration with the patients’ medical home team.
- Plans, implements and manages interventions for patients utilizing the PCBH model in conjunction with other clinical evidence based models of care suited to primary care.
- Determines and makes appropriate referrals to external providers and/or services.
- Completes documentation within the patient record adhering to standardized measures and guidelines.
- Facilitates psychoeducational sessions and mental health consultations for patients and the medical home team.
- Supports patients in navigating services, while maintaining principles of informational, relational and management continuity.
- Works in a flexible, responsive manner to provide nursing interventions in a variety of practice environments within the medical home.
- Provides additional/interim coverage as needed to Medical Home Clinics during PCBH provider absences and/or to address clinic PCBH access challenges.

Program Administration (10%)
- In collaboration with Program Manager and Clinical Supervisor, develops and evaluates policies, procedures, workflows and electronic health record processes for integrated care.
- Develops, reviews, approves and monitors clinical protocols, procedures and evaluation tools in consultation with Program Manager and Clinical Supervisor.
- Participates on relevant PCN committees/clinical working groups and prepares reports or presentations in consultation with Program Manager.

**Who Should Apply?**
- Bachelor's degree in nursing or social work required.
- Registration with relevant College as recognized by the Health Professions Act.
- Current CPR-BLS certification.
- Minimum of five years direct practice experience as a Registered Nurse or Registered Social Worker.
- Minimum three years' experience working within a medical home/integrated care model or primary care setting required.
- Experienced and trained in Primary Care Behavioral health models, Health behavior change methods (eg Motivational Interviewing, Health Change Methodology) and/or Cognitive Behavioural Therapy

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