Full Time Alternate Level of Care Community Nurse Job at Riverside Health Care

Job Description

The Alternate Level of Care (ALC) Community Nurse will ensure that hospital goals and objectives are met while creating an environment that supports the mission, vision, and values of the hospital, health centres, long-term care, and community programming; as well as ensures the creation of an environment for innovation and excellence in resident and client/patient-focused care.

Job Responsibility

Work to create/broaden partnerships with allied health and social wellness partners throughout the region to transition ALC patients more effectively from hospital to community programming, home, and long-term care (LTC)
Proactively engage with local and regional allied health and social wellness partners to develop pathways that will avoid ALC designations by addressing patient/client needs and barriers pre-emptively
Become involved in creating strategies that lead to early identification of potential ALC patients in the community and hospital setting
Examine causes of delayed transitions for ALC patients and, as part of an interdisciplinary team, design approaches to counter the delays
Collaborate with health partners to collect, analyse, and critically evaluate data as it relates to ALC patient trends for the Rainy River District
Facilitate transitions of care
Be physically present for warm hand-offs to ease the transition for the ALC patient moving from hospital to home care (nursing/PSS)
Be physically present for ALC patient discharges from hospital to home for those with little to no caregiver support
Complete regular, on-site check-ins for assessment of instrumental activities of daily living for this patient population
in facilitating transitions from Hospital to long-term care
Palliative/end of life transitions from hospital to home with Advanced Care Planning completed ahead of discharge
Be on hand for emergency department (ED) transitions of potential or diagnosed ALC patients
Complete in-home medication assessments for recently transitioned potential and/or ALC patients
Health system navigation for ALC patients/caregivers being considered for discharge as well as for clients identified in community as potential ALC patients
In collaboration with leadership, bring cases forward that would best utilize ALC flexible funding for ALC patient avoidance initiatives and improve ALC to discharge transitions
In collaboration with leadership and Riverside educators, create a training program and instruct staff on, Forethought in ALC patient avoidance at care transitions, Hospital ALC patient needs assessment, Care and treatment of ALC patients, ALC discharge planning considerations, Early recognition of potential ALC patients and ALC designation avoidance in community
Other duties as assigned, by Director, Community Services or designate

Requirements

University degree in Health or Social Sciences field
or College Diploma with five (5) years’ work experience in the health and /or social work field
Clinical experience
Experience in rural nursing, working with indigenous people
Knowledge of community programming, long term care, convalescent care and other health and services agencies – locally and regionally
Work experience in primary care
Knowledge of Informed Decision Making, Patient Capacity, Patient Rights an Consent for Treatment
Possess effective oral and written communication and organizational skills
Strong interpersonal and team building skills
Demonstrated initiative and experience working independently and with minimal supervision
Proven ability to develop and maintain effective working relationships with others both internal and external to the organization
Demonstrated critical thinking skills and problem solving
Knowledge of, and in compliance with relevant legislation in health and safety and employment, (OH&S Act and its Regulations, WSIB, Human Rights)
Physically capable of performing essential duties of the job
Regulated Health Professional or a relevant blend of education and experience deemed appropriate by Riverside Health Care
Social services work experience
Minimum of five (5) years of relevant experience in a health care setting
Experience in rural/remote healthcare, working with indigenous people
Demonstrated knowledge of local and regional community health and social service providers, an understanding of the long-term care system, comprehension of Ontario Health’s Home and Community Care Support Services
Proficient in using MS Office application, including MS Word, Excel, and PowerPoint, and other computer skills necessary for virtual modality’s of care, communication and research
Knowledge of Informed Decision Making, Patient Capacity, Patient Rights, Consent for Treatment, and Alternate Level of Care (ALC)
Ability to work autonomously and support the creation of program guidelines and materials
Must have a valid G class driver’s license and be in good standing
Travel throughout the region

Nice to have

Clinical experience is an asset
Experience in rural nursing, working with indigenous people is an asset
Work experience in primary care is an asset
Social services work experience is an asset
Experience in rural/remote healthcare, working with indigenous people is considered an asset

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Full Time Alternate Level of Care Community Nurse

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