Registered Nurse Care Coordinator

ABOUT US

ćećəwət leləm "Helping House" provides wholistic, culturally integrated health & wellness services for Indigenous clients and families. Our interdisciplinary teams include community health programming; primary care services; home care services; peer support, harm reduction, and crisis response; integrative therapy; wholistic wellness; and Indigenous Elders, Healers, and Knowledge Keepers. Together, we strive to support Tsleil-Waututh Nation members and families through care that is trauma-informed, relationship-centered, and guided by the Nation’s teachings on balance and interconnectedness.

JOB SUMMARY:

Reporting to the Health and Wellness Director, the RN Care Coordinator is responsible for supporting clients in developing, maintaining, and/or regaining their sense of wellbeing and independence at home and in the community.

DUTIES AND RESPONSIBILITIES:

Providing Home Care Nursing Services:

• Using a trauma-informed approach, promotes a culturally safe and therapeutic care environment in support of client self-advocacy and self-determination

• Performs comprehensive environmental assessment of the home, along with a thorough evaluation of client’s physical, cognitive, and psychosocial functioning to identify barriers to health

• Provides home care nursing assessment and nursing care throughout the adult and older adult health trajectory, including chronic disease management, wound care therapy, and end-of-life palliative assessment and nursing care

• Upon identifying client goals and needs, tailors individualized care plans in consultation with clients, their families, and members of the interdisciplinary team, providing joint home visits with other team members as needed

• Implements evidence-informed interventions that respect self-determination, strengthen self-management, and bolster engagement in meaningful activities, while supporting family and caregiver capacity

• Maintains accurate documentation and reporting of outcome measures consistent with TWN policy and professional standards of practice

• Using a trauma-informed approach, promotes a culturally safe and therapeutic care environment in support of client self-advocacy and self-determination

Care Coordination & Caseload Management:

• With cultural sensitivity and humility, fosters care relationships with clients and their self-identified families and support persons to help establish rapport, trust, and mutual respect

• Assesses client’s health and functional status, along with their informal support network, and bolsters integrity of supports as needed, by way of advocacy, shared care planning, and integration of additional formal supports and resources

• Promotes client independence, participation, and wellness by using a care coordination process of client assessment, care planning, implementation, and ongoing evaluation and re-assessment as needed

• Provides direction to home support staff by creating client-specific home support service plans which delegate home support service tasks in support of client independence with their iADLs and ADLs

• Monitors and evaluates both clinical care plans and home support service plans to ensure optimal and effective care delivery

• Initiates and participates in care conferences with clients, families, interprofessional team members, and service providers to help ensure a coordinated and integrated approach to client care

• Supports clients’ access to health services and helps clients and families navigate resources and overcome personal and systemic barriers to accessing care and achieving health & wellness

• Effectively consult and confer with various team members in support of interdisciplinary collaboration and shared care planning

Supporting Continuity of Care:

· Anticipates medical and functional changes over time, especially in the context of serious illness or chronic disease and provides avenues for early engagement and conversations with clients and families to ensure care planning is guided by clients’ and families’ goals, wishes, and values

· Ensures continuity of care over time and with any changes in client condition, including hospitalization

· Effectively addresses systemic barriers to ensure seamless care transitions, improve access to care services, and support continuity of care, engaging closely and collaboratively with all internal and external partners

· Facilitates safe and effective transitions of care between hospital and home by liaising with the acute care team throughout the hospital stay, and ensuring effective and timely communication and follow-up post hospital discharge

· Identifies community and cultural resources, assists clients in accessing benefits or supports, and advocates for equitable, client-centered services

· Coordinates ongoing care as well as access to TWN specific programming such as primary care, mental wellness, recreation, housing, etc. and supports referrals to external health and community services as needed

Supporting Community Health & Wellness:

· Guided by the vision, goals, and strategic plan of Tsleil-Waututh Nation, supports population-wide initiatives to augment client, family, and community wellbeing

· Supports community preventative and proactive care and education initiatives and workshops that support health and wellness

· Acts as a clinical resource for the interdisciplinary team by providing information based on nursing theory and practice as related to clients with complex health care needs

· Provides education to home support staff on topics like supporting palliative care clients in the home, medication management, dementia care, etc.

· Liaises with Indigenous Elders, Healers, and Knowledge Keepers to foster connection, cultural engagement, and strength-based healing & recovery

· Contributes to community wellness programming, prevention initiatives, and outreach efforts that strengthen the community’s social determinants of health

· Contributes to continuous quality improvement by identifying gaps in community services and resources, and participates in program planning and development

Ensuring Continuous Education & Professional Development:

• Engages in ongoing learning opportunities to support continuing education and professional development

• Stays current and pursues continuous professional development by attending conferences, caucuses, events, and symposia on Indigenous health and wholistic wellness as requested by the Director

• Upholds best practice standards in nursing care and is deeply committed to excellence, consistency, and continuous improvement in professional and ethical conduct

Performs other home care nursing & care management duties as assigned by the Director.

QUALIFICATIONS:

Required qualifications

• Current practicing registration that is in good standing, as a Registered Nurse (RN), with the British Columbia College of Nurses and Midwives (BCCNM)

• Graduation from an approved School of Nursing with a Bachelor’s Degree in Nursing

• A minimum of 3 to 5 years of relevant professional experience including home care nursing, case management, interdisciplinary team collaboration, and palliative care

• Valid BC Driver’s License – Class 5

• Reliable vehicle and current vehicle insurance

• Basic Life Support (BLS) certification

• Documentation of immunization and TB screening history

• Criminal Record Check (vulnerable sector)

• Able to lift up to 25 pounds

Preferred Qualifications:

• Completion of Indigenous Cultural Safety and Humility training (e.g. San’yas)

• Experience working within or alongside First Nations communities or Indigenous-led health organizations

KNOWLEDGE, SKILLS, & ABILITIES:

• Broad and comprehensive knowledge and expertise in nursing assessment, care planning, care management, and care evaluation

• Self-directed with demonstrated organizational skills, working independently, and in collaboration with others

• Proven ability to use tact and sound judgment in decision-making, and when dealing with sensitive and complex issues

• Demonstrated ability in maintaining strict confidentiality

• Demonstrates professional accountability, integrity, and humility in clinical practice

• Demonstrated knowledge and skills in care coordination, case management, clinical consultation, and care conferencing

• Exceptional oral and written communication, conflict resolution, and de-escalation skills, which effectively support meaningful connection, interpersonal relations, and collaborative team dynamics

• Deeply self-aware, reflective, and emotionally grounded, demonstrating a genuine, kind, and gentle approach in relating to others, offering compassion and care to support the well-being of clients and their family members

• Ability to make effective referrals, identifying gaps in services and reflecting an in-depth knowledge of community resources and strong collaborative skills in working with other community partners

• Ability to continue to strongly advocate for and support clients, while being witness to the ongoing impacts of systemic racism and population health disparities

• Brings a strong ethic of client service and is knowledgeable about the cultures and traditions of diverse Indigenous Nations

• High level of emotional intelligence, integrity, and patience

WORKING CONDITIONS:

Physical Demands

• Intermittent physical activity including walking, standing, sitting, lifting and supporting clients.

• May be exposed to occupational hazards such as infectious waste, diseases and chemicals.

• Manual dexterity required to use desktop computer and peripherals.

Mental Focus

• May deal with individuals who can, from time to time, be demanding and challenging. Must be able to remain patient and calm, and may have to engage in conflict resolution.

Environmental Conditions

• The noise level is generally quiet, but at times noise could escalate.

• Must be able to work relatively independently and deal with issues of personal safety because this position is outside the controlled environment of a hospital.

We appreciate everyone’s interest in the role, however only shortlisted applicants will be contacted.

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