Nurse Navigator - Seniors Home Support Program (10437)

Overview

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Position summary

The Seniors Home Support (SHS) Program was launched by the Eastern York Region North Durham (EYRND) Ontario Health Team to provide interdisciplinary primary care to homebound seniors who for medical, social or cognitive reasons cannot access office-based primary care services.

As Nurse Navigator, you will work closely with members of the team including family physicians, community paramedics, and allied health providers.

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Who you are

You encompass Oak Valley Health’s core values and live the words of respect, trust, commitment, compassion and courage. You are a patient and / or client centered individual who performs at an exemplary standard.

You are a team player with excellent communication, critical thinking and prioritization skills. 48 Scheduling Created with Sketch.

Schedule

The successful candidate will be available to work Monday- Friday, Days, 8-hour shifts, as per schedule. Please note, schedule is subject to change based on operational needs.

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Compensation

Band J- $ - $ per hour 48 Innovation Created with Sketch.

Contract length

Full Time Temporary (Approx. until March 2025)

Responsibilities

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Support

Support SHS referrals or urgent clinical referrals as needed. Relay relevant patient messages to most responsible practitioner (MRP) / interprofessional team.

Fill out appropriate referral forms to community programs (, palliative team, LTC, behavioural support services, etc.) and follow-up to ensure warm transfer.

Support and navigate both patients and their caregivers with access to appropriate community support services. 48 Communication Created with Sketch.

Communication

Triage and respond to patient concerns on a daily basis; Liaise with physicians, NP, interprofessional team, community paramedics and home and community care to action and modify clinical plans as required.

Provide urgent telephone follow-up to patients (, follow-up for key incomplete tests, close monitoring of unwell patients recently started on antibiotics at home, follow-up fluid overloaded patients).

Close communication loop and provide updates to MRP. 48 Prepare Created with Sketch.

Coordinate

Meet clients and their caregivers in ED / hospital - if unable to meet in person, connect with ED clinical team to ensure warm handover.

Work collaboratively with Markham Stouffville Hospital’s patient flow coordinators to inform them about patients and their transfer to community programs.

Manage routine medical-related concerns (pharmacy clarifications, missing lab requisitions, IV antibiotics, flu shot questions, and outstanding tests).

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Quality assurance

Check emails for notifications for ED / inpatient patient admissions. Participate in use of tracking codes in Accuro to document work for KPI / QI purposes.

Document all patient interactions on Accuro; complete clinical notes in Accuro within 24h. 48 Performance Created with Sketch.

Performance

Advocate, navigate and facilitate access to hospital resources. Educate, promote and increase SHS Program awareness amongst internal (Markham Stouffville Hospital) and external stakeholders ( networking with physician groups, clinical teams, discharge planners, HCCSS, etc.

Attend team meetings regarding program operations, planning, and evaluation. Provide cross-coverage for team coordinator or other team members as needed.

Requirements

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Qualifications

Registered Nurse, current registration with the College of Nurses of Ontario. BSCN preferred, or evidence of working toward.

Strong telephone triage skills. Experience working with geriatrics patients with complex medical needs strongly preferred (acute care experience is also highly valuable).

Experience working within an interprofessional team environment as well as independently and autonomously with efficiency.

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Skills

Must be flexible and able to prioritize multiple incoming requests. Excellent interpersonal and decision-making skills. Strong organizational and multi-tasking skills.

Demonstrates strong sense of accountability toward patient care and reflects on learning goals. Computer literacy required;

experience with Meditech and Accuro an asset. Experience of knowledge of existing programs and services within Markham Stouffville Hospital is an asset (but not mandatory).