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Community Care Coordinator
2 months ago
We are seeking a highly skilled and compassionate Registered Nurse to join our team as a Geriatric Care Specialist. In this role, you will be responsible for providing comprehensive geriatric care to patients in their homes, hospitals, and long-term care facilities.
Key Responsibilities- Conduct comprehensive geriatric behavior assessments using the PIECES framework and supporting geriatric assessments.
- Liaise with care teams, including patients, caregivers, and healthcare professionals, to develop and implement individualized behavioral care plans.
- Collaborate with healthcare teams to coordinate and integrate care plans, ensuring seamless transitions between care settings.
- Conduct Best Possible Medication Histories and share with care teams to ensure safe and effective medication management.
- Work collaboratively with primary care physicians, geriatricians, and geri-psychiatric specialists to provide updates on patient status and recommend follow-up visits.
- Address client and caregiver questions and concerns, providing education and support to promote behavioral management.
- Assess, consult, and treat as indicated, utilizing an ABOE approach and communicating observations to care teams and caregivers.
- Document assessments and care plans in CHRIS, OSLER, and MEDITECH databases.
- Participate in data entry to track program metrics and contribute to quality initiatives.
- Act as a spokesperson for the LHIN, interpreting the role of the LHIN to clients, healthcare professionals, and the public, ensuring positive public relations and effective coordination of services.
- Participate in the orientation of new staff and students, providing refresher training as assigned.
- Assess for and promote a safe environment for clients, caregivers, family members, and staff, adhering to health and safety policies and practices.
- Ability to assist staff and family members in developing and implementing behavioral care strategies and monitoring patient responses.
- Demonstrated commitment to the LHIN's mission and values.
- Working knowledge of community resources and roles of healthcare professionals.
- Solid knowledge of healthcare-related legislation and practices.
- Knowledge of direct care and case management models used in community healthcare organizations.
- Knowledge of LHIN priorities, policies, practices, and service standards.
- Registered Nurse (BScN or diploma) in good standing with the College of Nurses of Ontario.
- Completion of a Case Management Certificate is an asset.
- Completion of training and experience using this model.
- GPA (Gentle Persuasive Approach) essential.
- Demonstrated experience meeting documentation standards of the College of Nurses of Ontario and organizational expectations.
- Crisis Prevention Intervention Training an asset.
- CNA certification in Geriatrics preferred.
- Current CPR certification.
- Minimum of two (2) years of experience as a Registered Nurse in a mental health setting and/or specialized geriatrics unit with experience in dementia care.
- Specialized skills in assessment of delirium, dementia, and mental health, with knowledge of multiple best practices in these areas.
- Ongoing annual recertification BCLS/BLS or CPR - BCLS/BLS for Healthcare Provider or CPR Healthcare Provider level current.
- Experience working with diverse patient groups, including multicultural, homeless, palliative, acquired brain injury (ABI), mental health, geriatrics, and pediatrics.
- Case management experience or recent related community experience.
- Ability to speak French or another second language.
We know wellness is supported with work-life balance. In an inclusive culture committed to supporting your passion for continuous learning, growth, and innovation, we offer:
- Attractive comprehensive compensation packages and benefits.
- Valuable development opportunities.
- Membership in a world-class defined benefit pension plan.
We are Home and Community Care Support Services, ready to serve every person in Ontario. We partner with patients and caregivers, family physicians, hospitals, long-term care and retirement homes, service providers, and Ontario Health Teams to deliver responsive, accessible, integrated, patient-centered care.
