Care Management Coordinator, Clinical Operations

Why Fraser Health?:
Fraser Health is responsible for the delivery of hospital and community-based health services to over 1.9 million people in 20 diverse communities from Burnaby to Fraser Canyon on the traditional territories of the Coast Salish and Nlaka’pamux Nations. Our team of 43,000 staff, medical staff and volunteers is dedicated to serving our patients, families and communities to deliver on our vision: Better health, best in health care.

Effective October 26, 2021, all new hires to Fraser Health will need to have full COVID 19 vaccination (have received a full series of a World Health Organization “WHO” approved vaccine against infection by SARS-COV-2, or a combination of approved WHO vaccines). Please note this applies to all postings, and individual medical exemptions must be approved by the Provincial Health Officer.

Curious to learn what it’s like to work here? Like us on
**Twitter** &
**LinkedIn** (fraserhealthcareers) for first-hand employee insights.

Detailed Overview:
In accordance with the British Columbia College of Nurses and Midwives (BCCNM) standards of practice as well as within a patient and family centered care model and the Mission and Values of Fraser Health, the Care Management Coordinator, in collaboration with the Patient Care Coordinator and the interprofessional team, facilitates patients' hospitalization from admission through discharge. Coordinates and collaborates with the interprofessional team to expedite effective, quality patient care and coordinates timely and sustainable discharge plans. Intervenes to address barriers and provides leadership as needed to achieve optimal outcomes including helping to expedite additional services as required. The Care Management Coordinator is accountable for the development and effectiveness of policies, procedures and standards to support effective care management and discharge planning. Evaluates progress towards desired outcomes to ensure plan of care and services provided are patient-focused, of high quality, efficient and effective.

**Responsibilities**:

- Coordinates care and discharge planning for patients; proactively collaborates with the Patient Care Coordinator, physician and interprofessional team to determine discharge goals. Works closely with the home health liaison team to determine available services and prioritize discharge planning activities based on patient level of need/risk. Leads interdisciplinary rounds by facilitating care planning with the health care team and other stakeholders. Focuses team members on developing medical/functional goals as well as discharge plans to ensure a safe, appropriate and timely discharge.
- Facilitates patient flow activities by identifying patients requiring specialized attention in order to move effectively through the system. Coordinates patient transfer to alternate level of care. Acts as a resource/advisor for referral to services relative to diagnoses and post-discharge care.
- Observes, monitors and evaluates assigned patient progress, symptoms and behavioral changes by reviewing patients' daily status, anticipating responses to care, and identifying problems or variances from the expected care plan; conducts comprehensive nursing assessments if required. Intervenes to facilitate resolution of problems and removal of barriers. Reorganizes priorities and collaborates with the physician and interprofessional team to revise care plans as required to ensure that the plan of care and services provided are patient-focused, high quality, efficient and effective; includes patient/family in evaluating progress towards their goals.
- Develops and recommends policies, procedures and standards to support effective care management and discharge planning. Consults and collaborates with physicians and other health care professionals/providers in the identification and resolution of a variety of patient care issues by methods such as coordinating multidisciplinary team conferences, utilizing established acute care standards, allowing for individual variances, and developing partnerships with other facilities. Identifies and resolves potential barriers to efficient care delivery through collaboration with the Manager, Clinical Operations, Patient Care Coordinator and the interprofessional team.
- Coordinates and leads case conferences/meetings with patients, family and service providers for resolution of patient care issues; identifies concerns and discusses follow-up care. Acts as patient advocate to protect and promote the patient's right to privacy, dignity and access to information and to ensure the patient's choice and autonomy in decision making and care planning.
- Acts as a resource to staff, patients and families regarding care management and discharge planning. Works proactively to expedite additional services required in order to facilitate a smooth transition for patients from hospital to the post-hospital setting. Works in collaboration with the Home Health Lia