Care Management Coordinator

1. Assesses patients and collects information from a variety of sources using skills of observation, communication, data review and physical assessment. Makes a nursing diagnosis of the patient's condition and determines whether the condition can be improved or resolved by an appropriate nursing intervention. Plans, performs and evaluates nursing interventions and care.
2. Collaborates with patients and their families/care givers in developing the care plan and encourages family participation in the development, implementation and ongoing modification of the care plan. Establishes a therapeutic relationship by demonstrating empathy, trust and respect, advocating for the patient's rights to privacy, dignity and access to information, and by ensuring the patient's choice and autonomy in decision making and care planning.
3. Participates in the care and discharge planning process for patients on admission by ensuring the care plan is established and implemented effectively, updating care plan and intervening as appropriate, collaborating with the interprofessional care team to ensure comprehensive care planning and delivery, and collaborating and communicating with the Patient Care Coordinator on issues that will affect the care/discharge plan.
4. Coordinates nursing care for the patient; sets priorities, assigns and delegates tasks to support staff, and makes referrals to the interprofessional care team according to established protocols and practice standards.
5. Collaborates with members of the interprofessional care team including Physicians, Licensed Practical Nurses, Patient Care Coordinator, Clinical Nurse Educators, and other health care professionals/providers in the identification and resolution of issues, adjustments to care plans as required, and in regard to changes in patient condition.
6. Teaches patients and families/care givers about illness prevention, health restoration and health maintenance to help patients accomplish their health care goals. Assesses learning needs of the patient and family/care giver; provides information and demonstration of care activities to support self-care and the discharge plan.
7. Plans and discusses referral information with patient and their families/care givers and, in collaboration with members of the interprofessional care team, initiates referrals to appropriate health care/community agencies.
8. Documents assessments, nursing diagnosis, observations, interventions, patient/family responses, outcomes/evaluations, and referrals according to practice standards and Fraser Health procedures.
9. Participates on nursing committees, care conferences and councils as assigned or as agreed to with the Manager.
10. Participates in research and quality improvement activities by identifying patient care issues, collecting data, and identifying needs and recommendations for corrective action and changes to practices, procedures or protocols.
11. Participates in and attends in-services and other educational programs. Identifies own learning goals and maintains and updates current clinical competence and knowledge within area of practice.
12. Acts as a preceptor or mentor to assigned new nursing staff and students; shares information, demonstrates care activities, participates in orientation.
13. Provides feedback to the Manager/delegate regarding the effectiveness of patient care programs, policy/clinical decision support tools (e.g. clinical pathways, standards, order sets and procedures), and equipment.
14. Performs other related duties as required.

• Ability to complete initial and ongoing patient assessment (clinical and diagnostic reasoning) and provide nursing care through appropriate/prescribed technical, therapeutic, safety type interventions.
• Ability to communicate effectively with patients, families/care givers, the public, medical staff and members of the interprofessional care team using verbal, written and electronic communication means.
• Ability to promote person-centered care that demonstrates empathy for patients and families/care givers, sensitivity to diverse cultures and preferences, and patient advocacy.
• Ability to integrate and evaluate data from multiple sources to problem-solve effectively.
• Ability to teach and instruct patients and families/care givers about topics essential to their health care and well-being.
• Ability to organize and prioritize work.
• Ability to collaborate with and promote cooperation among members of the interprofessional care team.
• Ability to use factual information, prior learning and basic principles and procedures to support nursing decisions and actions with relevant research-based evidence/evidence-informed practice.
• Ability to operate related equipment including relevant computer applications.
• 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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