Longitudinal Case Manager (LTCM)
Victoria, BC
Are you a registered nurse looking for a connection to Primary Care Practices so that you can provide case management for a subset of complex patients aged 65+ with multiple co-morbidities?
Role
SERVICE TO PROVIDERS:
As a dedicated RN Case Manager, you’ll provide a single point of access to team-based care for at-risk senior patients, including:
- Complete comprehensive patient assessment, including cognition and frailty
- Follow-up case conferencing
- Complete referrals to clinicians and services such as Rehab, Social Work, Geri-Psych Geriatric Specialty Services, and home supports as needed
- Conducting medication reviews and management while working with the PCN Patient Medical Homeal Pharmacists Program
- Opportunities to conduct joint visits with the FP/NP as appropriate and meeting with patients at the Patient Medical Home as needed
SERVICE TO PATIENTS:
You’ll provide enhanced patient-centred care and prevention of health crises – keeping at-risk patients safe, and at home, for as long as possible. This could include:
- Connecting patients and caregivers with primary and Community Health Services including Victoria PCN allied health resources
- Providing patient education/coaching for self-management
- Assessing, setting up, and monitoring Community Health Services Home Support services
- Supporting Advance Care Planning for end stage disease
- Facilitating patient transitions between care settings
The Family Physician/Nurse Practitioner and Case Manager will communicate and collaborate on patient prioritization
Scope of Care
- Performs a variety of functions related to case management and care coordination including assessing, organizing, and evaluating the needs of the patients and their caregivers/families
- Plans, participates, and facilitates client care conferences
- Provides leadership, fosters partnerships, and works co-operatively to achieve client care goals
- Fosters continuity of client care by liaising with primary care physicians, long-term care facilities, acute hospitals, and other programs/organizations
- Acts as a resource by communicating and educating clients, caregivers/families and the community about services, policies, and procedures
- Utilizes computerized systems to maintain client records, including obtaining and entering client demographics, histories and charts as required, in accordance with policies, procedures and professional practice standards
- Contributes to the orientation and training of staff, students, and other health professionals
- Participates in quality assurance activities and projects as required
- Contributes to the development of client-centred standards based on best practices
- Ensures a safe and healthy working environment by observing and promoting universal precautions and infection control procedures; removing obvious hazards; reporting faulty equipment, accidents, injuries and near misses; and adhering to and enforcing rules regarding safety.
Qualifications
Registration with BC College of Nurses and Midwives as a practicing RN registrant. Three (3) years recent related experience in gerontology, including two years community health experience; or an equivalent combination of education, training, and experience. Valid BC Driver’s license.
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