Nurse Navigator - Seniors Home Support Program- Temporary; Approx

Land acknowledgement:

Oak Valley Health honours the traditional territory of the closest Indigenous communities, the Chippewas (chi-puh-waas) of Georgina Island and the Mississaugas of Scugog Island. The Haudenosaunee (Ho-de-no-shau-nee) and Anishinaabe (Ah-nish-in-ah-beh) have lived, worked and existed on this land from time immemorial. This land is covered by Treaty 13 signed with the Mississaugas of the Credit, and the Williams Treaty signed with many Mississauga and Chippewa bands.

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

What we are looking for:

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.

The primary role of the Nurse Navigator is providing virtual telephone triage of health concerns for patients enrolled in the SHS program

Responsibilities include, but are not limited to:

· Primary point of contact throughout the patient care journey

· 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

· 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 (i.e. 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

· Advocate, navigate and facilitate access to hospital resources

· Educate, promote and increase SHS Program awareness amongst internal (Markham Stouffville Hospital) and external stakeholders (i.e. networking with physician groups, clinical teams, discharge planners, HCCSS, etc.)

· Check emails for notifications for ED/inpatient patient admissions

· 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

· Provide urgent telephone follow-up to patients (e.g. 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

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

· 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

· Attend team meetings regarding program operations, planning, and evaluation

· Provide cross-coverage for team coordinator or other team members as needed

What you bring to the role:

· Registered Nurse, current registration with the College of Nurses of Ontario

· BSCN preferred, or evidence of working towards

· 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

· 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…