Care Management Leader

Job Description

Reporting to the Manager, Care Management & System Navigation, the Care Management Leader practices in accordance with the standards of professional practice and code of ethics as outlined by the British Columbia College of Nurses and Midwives (BCCNM) as well as within a client and family centered care model and the vision and values of PHC. From the point of admission, coordinates and collaborates with the acute interprofessional team to expedite effective patient care and coordinate timely sustainable discharge plans. Conducts comprehensive nursing assessments and provides direction to the interprofessional team on appropriate level of care, interventions to address barriers, resources necessary to achieve optimal outcomes including securing funding and approvals for services as required. Is accountable for the development and effectiveness of policies, procedures and standards to support effective care management and discharge planning. Participates in committees, task groups, continuing education, and/or corporate initiatives. Applies the use of data in own practice; identifying where to focus efforts, the measurement of progress towards identified outcomes, and as an educational tool to ensure that the plan of care and services provided are patient focused, high quality, efficient, and effective.

Education
Current practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives (BCCNM). Three (3) years recent, related experience including (1) year of experience in community care and discharge planning or an equivalent combination of education, training and experience.

Skills and Abilities
Comprehensive knowledge of Nursing theory and practice within a patient/family centred model of care.
Comprehensive knowledge of the BCCNM standards for nursing practice.
Broad knowledge of evidence based nursing practice related to various patient population groups and demonstrated ability to apply knowledge to a case management process.
Broad knowledge of pathophysiology and pharmacology, and demonstrated ability to apply knowledge to safely-plan discharge.
Broad knowledge of biological and pathophysiological indicators related to severity of illness to apply medical appropriateness criteria to resource utilization and transition/discharge planning.
Broad knowledge of the illness or disease process and potential long-term complications.
Broad knowledge of other health care disciplines and their role in patient care.
Broad knowledge of clinical pathways, expected length of stays, resource utilization, and patient assessment.
Broad knowledge of external agencies and community resources.
Demonstrated ability to engage in comprehensive assessment, observation and monitoring of patients.
Demonstrated ability to plan, organize, and prioritize work.
Demonstrated ability to analyze situations, problem solve, deal with conflict, and negotiate resolutions in a timely manner.
Demonstrated ability to provide leadership, work direction and consultation.
Demonstrated ability to work independently and as a member of an interprofessional team.
Demonstrated ability to develop and maintain collaborative working relationships and communicate (orally and in writing) effectively with clients and their families, coworkers, physicians, other health care staff, and staff of external agencies.
Demonstrated computer skills including the ability to effectively use computerized client care information system.
Physical ability to carry out the duties of the position.

Leads care coordination / discharge planning for assigned patients by proactively collaborating with the interprofessional team in acute and community to determine discharge goals, sub-acute and rehabilitation needs, and appropriate community service availability. Leads daily care rounds and focuses team members on developing medical/functional goals as well as a discharge plan for patient that ensures a safe, appropriate and timely discharge. Assigns tasks related to implementation of the discharge plan.
Facilitates patient flow activities by identifying patients requiring specialized attention or alternate levels of care in order to move effectively through the system. Acts as a resource/advisor for referral to services relative to diagnoses and post-discharge care.
Observes, monitors, and evaluates assigned patients progress, symptoms, and behavioral changes by reviewing patients’ daily status. Anticipates patient responses to care, identifies problems or variances from the expected care plan, and intervenes to facilitate resolution of problems and removal of barriers. Reorganizes priorities and collaborates with 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 developing goals evaluating progress towards them.
Develops and recommends policies, procedures and standards to support effective care management and discharge planning.
Consults and collaborates with physicians, external case managers, interprofessional team members, and other health care professions/providers in the identification and resolution of a variety of patient care issues by methods such as: convening, leading and participating in multidisciplinary team conferences as needed; defining appropriate lengths of stay targets for patients by following a standard of care as defined by clinical practice guidelines, protocols and clinical pathways, allowing for individual variances; developing linkages/partnerships with other facilities and services; and identifying and resolving potential barriers to efficient care delivery through collaboration with the Patient Care Manager, Clinical Nurse Leader and the interprofessional team.
Acts as patient advocate to protect and promote patients right to autonomy, respect, privacy, dignity, and access to information.
Acts as an expert resource to staff, patients and families associated with care management and discharge planning. Promotes collaboration on continuity of care issues, and resource coordination by methods such as assisting with the resolution of complex discharge issues, providing advice and supporting problem solving. Provides support and information to families, physicians and other professionals by methods such as supplying information about disease management, including relevant community and other external agency resources.
Communicates with external agencies to proactively secure funding and approvals for services outside the Community service area in order to facilitate a smooth transition for patients from hospital to the post-hospital setting.
Prepares and maintains concise and accurate patient records by methods such as documenting findings, discharge arrangements, contact with health care staff, and actions.
Promotes the development of best practice by identifying policies, procedures and processes requiring revision, recommending changes including care plan standardization and streamlining for efficient delivery of care, and drafting new and/or revised procedures, standards.
Participates in orientation of new team members by providing training and mentorship as required.
Participates in committees, task groups, continuing education, and/or corporate initiatives by methods such as providing input from a clinical perspective, presenting relevant material, and promoting optimal support for patients and their family to improve access, integration and coordination of health services.
Maintains and updates own clinical knowledge within area of practice and develops a plan in collaboration with designated personnel/team for professional development. Reviews progress to ensure that goals are achieved within established timeframes.
Performs other related duties as required.

As per the current Public Health Orders (Long Term Care/Seniors Assisted Living Provincial Health Order and the Health Sector Order), as of October 26, 2021, all employees working for Providence Health Care must be fully vaccinated against COVID-19. Proof of vaccination status will be required.