Access, Care and Transitions

Why Fraser Health?:
Fraser Health is responsible for the delivery of hospital and community-based health services from Burnaby to Fraser Canyon on the traditional, ancestral and unceded territories of the Coast Salish and Nlaka’pamux Nations, and is home to six Métis Chartered Communities.

Our team of 45,000 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. Learn more.

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.

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Detailed Overview:
In accordance with the British Columbia College of Nurses and Midwives (BCCNM) standards of practice and the Mission and Values of Fraser Health, ACT Coordinator performs a range of functions including allocation decision-making for Fraser Health non-acute bed resources such as long term care, assisted living, hospice and specialized mental health beds ensuring access for eligible clients at highest need. The ACT Coordinator also provides consultation advice, services coordination and monitoring as follows:
Acts as a resource and liaison to internal/external staff, agencies, clients and families regarding information and issues related to long term care facilities contracted by Fraser Health; collaborates with contracted service providers to resolve complex client specific issues. Mediates and supports contracted facilities and residents/families in the resolution of issues. Facilitates the implementation of policies and procedures relevant to long term care in a manner that respects the clients' and families' needs and the characteristics and strengths of the individual facilities.

**Responsibilities**:

- Receives, reviews and processes assessments forwarded for care and transitions team. Maintains and ensures communication of all current information regarding need and urgency for clients in assigned areas.
- Monitors acute care sites and works collaboratively with Site Access Coordinators and other acute care team members to facilitate new admissions, sets priorities for bed allocation across Fraser Health in a way that responds to individual client and acute care systems with highest need and greatest urgency.
- Manages the Priority Access and Transfer lists in accordance with procedures that are aligned with the Ministry of Health and Fraser Health policy.
- Acts as a resource and liaison to internal/external staff, agencies, clients and families regarding information and issues related to long term care facilities contracted by Fraser Health.
- Provides consultation and support to facility staff of contracted sites to effectively respond to identified issues of risk. Promotes clinical practice protocols/guidelines and standards and collaborates with long term care facilities to resolve complex resident specific care issues.
- Identifies issues of concern to the health and safety of residents during facility visits and, when required, reviews the care planned or provided, observes and evaluates resident goals, actions and outcomes and provides input into appropriateness with care. Advises and/or arranges for further care needs assessments by outside agencies or within Fraser Health, as required. Acts as a liaison between referring care teams and receiving facilities/hospice to facilitate admissions. Provides clinical guidance to these teams for developing care plans to meet complex client needs at time of admission.
- Mediates and resolves issues of dispute between facility and resident and families. Supports management of client feedback activities. Documents findings and outcomes.
- Reports risk concerns as appropriate. Identifies and arranges to relocate residents to alternate facilities when clinical capacity and/or physical environment is not appropriate to care needs.
- Responds to Adult Guardianship concerns by reviewing and investigating the reported situation and providing consultation to care facility staff. Implements Adult Guardianship legislation. Liaises with the Office of the Public Trustee or other external agencies as required. Completes reports and makes recommendations on risk issues.
- Acts as the Health Care Provider and completes financial incapability assessments as required. Complete assessments regarding the HCCCFAA process.
- Receives and review