Home Health Registered Nurse Liaison - White Rock

Fraser Health is responsible for the delivery of hospital and community-based health services to over 1.9 million people in 20 diverse communities from Burnaby to Fraser Canyon on the traditional territories of the Coast Salish and Nlaka’pamux Nations.

Our team of 43,000 staff, medical staff and volunteers is dedicated to serving our patients, families and communities to deliver on our vision: Better health, best in health care.

Effective October 26, 2021 all new hires to Fraser Health will need to have full COVID 19 vaccination (have received a full series of a World Health Organization “WHO” approved vaccine against infection by SARS-COV-2, or a combination of approved WHO

Performs client assessments and acts as a liaison between the acute care facility and community care service to facilitate discharge planning from the acute care facility to the appropriate service in the community; assesses the client's care needs by completing various assessments and arranging for single or multi-service referrals to appropriate community services such as Home Health, Home Support, Residential and/or other related community services; collaborates with other community service providers to provide advice to the client, families and other health care professionals on the client's various discharge options; manages short term Home Support hours for clients waiting to be discharged and/or referred to a community service.

1. Arranges client referrals from staff within an assigned acute care facility that requires community care services upon discharge or a change in level of service.
2. Interviews and screens the client by gathering information from various sources; utilizes various client assessment tools to determine appropriate client care plan; reviews client care plan to determine appropriate service upon discharge such as home support, nursing care and/or residential care.
3. Initiates and facilitates the development of a client care plan with other members of the interdisciplinary team; reviews hospital admissions/discharges to maintain awareness of client movement between the acute care facility and community services.
4. Participates in discharge planning rounds in the acute care facility and facilitates timely discharge of patients ensuring appropriate resources are in place; assesses the patient's eligibility for appropriate community services and/or placements.
5. Liaises with the client, family, physician and other health care professionals to arrange for community services such as long term care, nursing care, home support and/or other community health services required for the client; ensures client receives access to appropriate information of available and eligible services.
6. Facilitates timely exchange and provision of information regarding client care between the acute care facility and the community service to allow for individualized discharge planning; works with community service providers to ensure client care needs are met.
7. Determines if client is capable of making decisions around client care plans, in collaboration with the interdisciplinary team; refers client to appropriate health care professional for assistance and follows procedures around patient incapacity, respecting the patient's right to privacy and confidentiality.
8. Completes and maintain complete documentation of client information such as forms, charts, records, statistical information and other related information, as required.
9. Participates in quality improvement activities of the program by providing input into the development of indicators, standards, practices and procedures; provides recommendations to the Manager.
10. Participates and assists in the orientation of new staff by developing and providing relevant information and materials; acts as a preceptor as appropriate; identifies self-learning needs and attends relevant educational programs, as needed.
11. Advises acute care staff on whether clients are receiving community care services including the tracking of the number of hours of services provided to the patient awaiting placement and discharge.
12. Performs other related duties as assigned.

Education and Experience

Graduation from an approved school of Nursing. One (1) year recent related clinical experience in acute care and/or community nursing and discharge planning, or an equivalent combination of education, training and experience.

Current practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives (BCCNM).

Skills and Abilities

• Knowledge of acute, chronic, rehabilitation and palliative health conditions
• Ability to communicate effectively both verbally and in writing
• Knowledge of broad health care services, community resources, agencies and their role and responsibility in providing a continuum of care
• Knowledge of Home Health policies and procedures as a component of a community care system within the broader health system
• Ability to effectively problem solve, manage and prioritize client caseloads
• Ability to develop and implement a client care plan including follow up
• Ability to work independently and as a member of an interdisciplinary team
• Ability to develop and maintain rapport with clients, families and other health care providers
• Ability to deal effectively with others in a interdisciplinary team
• Ability to operate related equipment including related software applications
• Physical ability to carry out the duties of the position.