Job Summary:

In accordance with the Mission, Vision and Values, and strategic directions of Provincial Health Services Authority patient safety is a priority and a responsibility shared by everyone at PHSA, and as such, the requirement to continuously improve quality and safety is inherent in all aspects of this position. Reporting to the Nursing Support Services (NSS) Program Manager, the Nurse Clinician Case Manager is responsible for initiating, facilitating and coordinating health care plans in collaboration with families, health professionals and community professionals/agencies for children with complex medical conditions living in their home communities. Activities include intake and referral triaging, coordinating and facilitating teaching and support for children/youth and their families and liaising with acute care and community agencies in a manner that is consistent with established policies, standards and philosophies of Nursing Support Services and British Columbia’s Children’s Hospital.

Duties/Accountabilities:

1. Initiates and coordinates assessments, responds to child/youth, family, health care teams, community professionals/agencies and services providers enquiries, providing anticipatory guidance and case management, participates in and oversees the coordination of care in community throughout the child/youth’s health journey with the program. Actively engages in ongoing assessments to determine continued eligibility and level of services.

2. Responsible for assessment and development of a health care plan that optimally supports the child/youth in their home community by performing duties such as receiving, collecting and documenting child specific information related to the child/youth’s complex medical condition, collaborating and problem-solving with families and other health care team and community professionals/agencies, assessing the urgency and appropriateness of service needs, triaging as necessary to mitigate delays. Facilitates re-direction for children/youth/families to other community resources as applicable.

3. Collaborates with other members of the health care team to promote and support holistic family-centered care in the child/youth’s community setting by performing activities such as reviewing patient/family history, developing individualized health care plans, and meeting with other members of the health care team to discuss and review their recommendations for the child/youth.

4. Coordinates teaching and support for children/youth with medical complexities and their families by identifying their needs which includes sharing of resources, referring to and liaising with other health care professionals as well as acting as a resource for other health care professionals.

5. Provides supportive case management to families by ensuring continued communication and partnership in the assessment, planning, implementation and evaluation of the health care plan throughout the care continuum as well as advocacy, information regarding program, team, or community health and educational resources, and referrals to appropriate community services and/or agencies

6. Acts as a liaison, as appropriate, between the program, the interdisciplinary team, and community health and educational services and agencies to clarify information, responsibilities and recommendations to ensure the needs of the child/youth and family are addressed.

7. Establishes a collaborative working relationship with in-patient facilities and community- based health care and service providers.

8. Liaises with appropriate community and professional groups, nursing staff and agencies, regarding complex medical conditions through consultation and teaching.

9. In collaboration with the Nursing Support Services Manager, develops policies, procedures and operational requirements related to the function of the NSS Program by observing service needs and providing plans that address patient and family needs, program operations and promotes effective use of resources.

10. Participates in quality management activities related to the function of the NSS Program and nursing practice through assessment, planning, implementation, and evaluation of strategic interventions to improve practice.

11. Collaborates, as appropriate, with the interdisciplinary team and or/ nursing colleagues on research-oriented opportunities.

12. Performs other professionally related duties as assigned.

Qualifications:

Education, Training and Experience

• Graduation from an approved School of Nursing with current practicing registration as an RN with the British Columbia College of Nursing Professionals (BCCNP).
• Three years recent related and progressively responsible experience in tertiary pediatric nursing or an equivalent combination of education, training and experience.
• CPR Training – Basic Cardiac Life Support (BCLS) – Level I.
• Valid BC Driver’s License and access to vehicle and ability to travel

Skills and Abilities

• Knowledge of community based services for children with complex medical conditions.
• Comprehensive knowledge of the British Columbia College of Nursing Professionals (BCCNP) standards for Nursing Practice.
• Comprehensive skill and expertise in tertiary pediatric services and related issues
• Excellent communication skills, both oral and written.
• Strong leadership and organizational skills.
• Ability to relate effectively to children and their families, dealing effectively with those experiencing stress and /or in crisis.
• Ability to collaborate and work effectively as a member of an interdisciplinary care team and function as a nursing resource.
• Ability to identify and resolve problems using therapeutic communication strategies.
• Ability to work independently to organise and prioritise multiple tasks.
• Physical ability to perform the duties of the job.
• Strong computer skills, including Excel, Word and PowerPoint and Internet Browsers.