Care Management Coordinator

1. Coordinates care and discharge planning for patients; proactively collaborates with the Patient Care Coordinator, physician and interprofessional team to determine discharge goals. Works closely with the home health liaison team to determine available services and prioritize discharge planning activities based on patient level of need/risk. Leads interdisciplinary rounds by facilitating care planning with the health care team and other stakeholders. Focuses team members on developing medical/functional goals as well as discharge plans to ensure a safe, appropriate and timely discharge.
2. Facilitates patient flow activities by identifying patients requiring specialized attention in order to move effectively through the system. Coordinates patient transfer to alternate level of care. Acts as a resource/advisor for referral to services relative to diagnoses and post-discharge care.
3. Observes, monitors and evaluates assigned patient progress, symptoms and behavioral changes by reviewing patients' daily status, anticipating responses to care, and identifying problems or variances from the expected care plan; conducts comprehensive nursing assessments if required. Intervenes to facilitate resolution of problems and removal of barriers. Reorganizes priorities and collaborates with the 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 evaluating progress towards their goals.
4. Develops and recommends policies, procedures and standards to support effective care management and discharge planning. Consults and collaborates with physicians and other health care professionals/providers in the identification and resolution of a variety of patient care issues by methods such as coordinating multidisciplinary team conferences, utilizing established acute care standards, allowing for individual variances, and developing partnerships with other facilities. Identifies and resolves potential barriers to efficient care delivery through collaboration with the Manager, Clinical Operations, Patient Care Coordinator and the interprofessional team.
5. Coordinates and leads case conferences/meetings with patients, family and service providers for resolution of patient care issues; identifies concerns and discusses follow-up care. Acts as patient advocate to protect and promote the patient's right to privacy, dignity and access to information and to ensure the patient's choice and autonomy in decision making and care planning.
6. Acts as a resource to staff, patients and families regarding care management and discharge planning. Works proactively to expedite additional services required in order to facilitate a smooth transition for patients from hospital to the post-hospital setting. Works in collaboration with the Home Health Liaison team.
7. Acts as a resource for the interprofessional team and promotes collaboration on concerns and continuity of care issues; assists with the resolution of complex discharge issues and provides advice and support to enhance problem solving and address patient care/service issues.
8. Prepares and maintains concise and accurate patient records by methods such as documenting findings, discharge arrangements, contacts with health care staff, and actions taken in accordance with Fraser Health and regulatory standards.
9. Promotes high standards of clinical practice and the development of best practice by participating in the revision and evaluation of clinical practice and systems; identifying policies, procedures and processes requiring review, recommending changes including care plan standardization for efficient delivery of care, and drafting new and/or revised procedures, standards and criteria for discussion with interprofessional team members and clinical leadership. Works in collaboration with Fraser Health Professional Practice and related councils.
10. Participates in orientation of new team members by providing training and mentorship as required.
11. Participates in committees, task groups, continuing education, and projects.
12. Performs other related duties as assigned.

Education, Training & Experience

Current practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives (BCCNM). Three (3) years recent, related acute care experience including one (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 centered model of care.
• Comprehensive knowledge of the BCCNM Standards of 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.
• Ability to apply knowledge of pathophysiology and pharmacology to safely plan discharge.
• 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.
• Ability to engage in comprehensive assessment, observation and monitoring of patients.
• Ability to plan, organize and prioritize work.
• Ability to analyze situations, problem solve, deal with conflict and negotiate resolutions in a timely manner.
• Ability to provide leadership and consultation.
• Ability to work independently in an organized and self-directed manner and also as a member of an interprofessional team.
• Ability to communicate effectively both verbally and in writing.
• Ability to operate related equipment including applicable software.
• Physical ability to perform the duties of the position.

Fraser Health is the heart of health care for over two million people in Metro Vancouver and the Fraser Valley in British Columbia, Canada, on the traditional, ancestral and unceded lands of the Coast Salish and Nlaka’pamux Nations and is home to 32 First Nations within the Fraser Salish region.

People - those we care for and those who care for them - are at the heart of everything we do. Our hospital and community-based services are delivered by a team of 48,000+ staff, medical staff and volunteers.

We are committed to planetary health and value diversity in the work force. We strive to maintain an environment of respect, caring and trust. Fraser Health’s hiring practices aspire to ensure all individuals are treated in an inclusive, equitable and culturally safe manner.

Together, we are the heart of health care.

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