Ensure effective transitions from acute to home care for the following target population: frail adults with complex needs and/or high risk characteristics. Ensure communication and linkage with primary care and provide timely and effective rapid response home care. The rapid response nurse provides the first in-home nursing visit within 24 hours from hospital discharge for high needs seniors and adults. During this visit, the Registered Nurse (RN) will confirm the patient hospital discharge care plan, communicate the importance of connection to primary care to avoid re-hospitalization, and perform medication reconciliation for the patient. The RN will collaborate with other members of the interdisciplinary team including care coordinators, nurse practitioners, Pharmacists and contracted service providers.
Core Duties & Responsibilities
- Review the discharge care plan and confirm that outstanding investigations have been scheduled and transportation is available. Liase with hospital staff and care coordinator in regards to discharge plan.
- Directly or in partnership with a pharmacist, ensure new prescriptions are filled and conduct a medication review and reconciliation. Review the medication protocol with the patients and/or caregiver and provide health teaching..
- Complete a nursing physical assessment in the patient’s home and provide health teaching to the patient and/or family regarding their illness and avoidance of re-occurance of acute episode.
- Ensure contact with primary care provider and provide an update on the patients acute care event and post discharge regime. Recommend and facilitate a follow up visit as appropriate and/or within 7 days after discharge from the hospital.
- Refer the patient to Health Care Connect if the client has no primary care provider
- Identify patients requiring an accelerated assessment and home care services and coordinate with the care coordinator and/or nurse practitioner to facilitate the assessment
- Collaborate with the care coordinator to develop the patient’s care plan and ensure a smooth transfer of the primary care provider and pharmacist to the ongoing care team
- Provide health teaching and information to the patient/caregiver and ensure they have CCAC contact information
- Act as a spokesperson as required and interpret the role of the CCAC to patients, healthcare professionals and to the public. Ensure positive public relations and effective coordination of services through ongoing liaison and participation in internal and external committees. Assess for and promote a safe environment for patients, caregivers, family members and staff. Adhere to health and safety policies and practices developed and implemented by the CCAC.
- Participate in establishing; maintaining and monitoring standards for HNHB direct nursing providers, including committee work and active participation and contribution to quality initiatives.
- Leads and/or participates in and demonstrates an understanding of quality, risk and patient safety principles and practices.
- Follows all safe work practices and procedures and immediately communicates any activity or action which may constitute a risk to quality, and patient safety.
- Perform other duties as assigned
Knowledge & Experience:
- Minimum of 5 years of relevant experience as a registered nurse
- Recent clinical/acute experience within 2 years.
- Working knowledge of community resources and roles of health care professionals
- Solid knowledge of health care related legislation and practices
- Knowledge of direct care/case management models used in community health care organizations
- Knowledge of CCAC priorities, policies, practices and service standards
- Registered Nurse. Baccalaureate preferred
- Case management certificate or experience is an asset
- Advanced education in gerontology and/or chronic disease management
Skills & Abilities
- Clinical Assessment skills
- Problem-solving and decision making skills
- Interpersonal communication skills (written and verbal)
- Negotiation skills
- Multi-tasking skills
- Accessing community resources
- Team Building
- Ability to work independently as well as in a team setting
- Collaboration with Internal and External stakeholders
- Organization, goal setting, planning, coordination and evaluation skills
- Computer experience and keyboarding skills on a lap top and desk top computers
- Flexibility during transition
- Valid driver’s license
- Access to a motor vehicle
- Driving to and from client visits
- Satisfactory Police Records Check and Vulnerable Sector Search
- Current CPR certification