Job Description

Job Number: J1123-0942

Job Title: Patient Flow Navigator - Patient Flow/Utilization

Department: Patient Flow/Utilization

Job Type: Permanent Full Time

Job Category: Nursing

Union: ONA

Open Positions: 1

Date Posted: November 28, 2023

Closing Date: December 4, 2023

Salary: $37.93 - $54.37/Hour


Hours of Work:
as scheduled






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Orillia Soldiers\xe2\x80\x99 Memorial Hospital (OSMH) is located in the City of Orillia - a beautiful community nestled along the shores of Lake Simcoe and Lake Couchiching. Orillia offers an environment where a health work/life balance is easy to achieve as exceptional urban amenities, natural resources, points of interest, and recreational opportunities abound.

People have always been OSMH\xe2\x80\x99s greatest strength. Our committed team has helped our community for over a century. We offer an environment where each individual works interdependently towards common goals: we value Trust, Courage and Teamwork. We are an organization where individuals\xe2\x80\x99 contributions are valued and there are many opportunities for personal growth and development.
Position Summary
POSITION SUMMARY:

The Patient Navigator promotes optimal patient and clinical outcomes by assessing and facilitating effective quality of care, utilization of resources and length of stay in acute care, complex continuing care as well as the Emergency department. The Patient Navigator will identify and initiate complex discharge or transition plans for high risk patients (including regional renal in patients) and collaborate with physicians, interprofessional teams and appropriate community partners and resources to support Home First philosophy and practices, Significant to this role is case management expertise and complex discharge planning activities. Within the acute care in-patient areas, this individual identifies and addresses clinical care processes and/or other issues impeding the flow of patient care from admission to discharge, when working in the Emergency department the patient navigator supports and enhances the flow of patients through the department identifying and facilitating hospital admission avoidance cases and supporting transition to admission or other discharge destination. There is a focus on frail seniors who are at risk of suffering adverse events, loss of independence and admission to hospital.
Patient navigation within Acute Care and the Emergency Department requires knowledge and understanding of quality improvement processes and OSMH performance metrics. It is expected this position will be assigned to provide patient navigation and complex case management/discharge planning in the acute in patient areas and the Emergency department, assignments will depend on needs of the Hospital.



PRIMARY RESPONSIBILITIES:

• Apply case management knowledge and skill to successfully support complex discharge planning, review the health record of complex medical and surgical admissions, assess and assist with implementation of plan of care, support team collaboration and transition of care activities to support discharge back to the community or next level of care
• Contribute to assessment of patient\xe2\x80\x99s medical, functional, cultural, and psychosocial needs, family issues/dynamics, extent of community resources in light of input/assessments from the multidisciplinary team and community partners re: identified needs and care options to facilitate transition through care continuum
• Facilitate safe patient discharge through: ongoing assessment, case coordination and development of appropriate discharge plan. Included but not limited to: patient/family education, referral and completion of application to specialized programs, coordination of family meetings,
• Provide ongoing re-evaluation of discharge plan especially if other special needs identified, e.g. significant behavioral/psychiatric concerns. Provide consultation and coordination of legal/financial capacity or SDM issues including potential PGT involvement. Facilitate interdepartmental, inter-hospital and interprofessional communication amongst the team with patients and families.
• Demonstrated excellence in interview skills, coordinate and lead family meetings in support of transitions and facilitation of program referrals
• Demonstrated understanding and knowledge application of community programs and services. Able to identify appropriate patients for services and successfully complete applications for community programs, CCAC programs/services (including CCC, CCP and LTC programs)
• In collaboration with the health care team, facilitate and coordinate appropriate consultations, treatments, tests and procedures to expedite completion within a recommended timeline.
• In collaboration with the health care team, information technology and decision support department, review and validate statistical data from UMS, RFD, EDD, LOS on a daily basis and implement and document plan of care changes as appropriate.
• Maintain an in depth knowledge of community resources, facilitate partnerships through daily interface and collaboration with our community partners such as Community Care Access Centre (CCAC), community agencies, retirement homes and Long-Term Care Homes.
• Advocate for ALC designation when acute medical treatment is completed and complete appropriate documentation.
• Demonstrate competency and comprehensive understanding in Alternate Level of Care (ALC) knowledge application.
• Attend, participate and/or lead ALC rounds, Daily Bed Meeting , Weekly program Huddles, and hospital/community committee work
• Acts as resource and leader
• Participate, facilitate and support corporate patient flow and quality improvement initiatives.
• Other duties as assigned by program manager

In Patient Responsibilities

• Develop concise case summaries, present cases to Joint Discharge Operations Committee and at ALC rounds
• Collaborate and partner with Regional renal program team members including social workers, team lead, nephrologists to support discharge and transition plans for the regional renal patients
• Attend weekly renal rounds

ED Responsibilities

• Review all potential patients considered for admission, and those at high risk for admission, in collaboration with the interprofessional team explore appropriate alternatives to admission.
• Collaborate with the ED interdisciplinary team, bed allocation, Patient Flow Team and team leaders to coordinate timely admission to the most appropriate level of care and inpatient location, document transition of care plan as appropriate.
• Coordinate navigation activities and information handover with Patient flow Team to ensure optimal hospital wide patient flow minimizing admission, discharge and transfer peaks and pressures and departmental functional processes.
• Conduct assessments utilizing the automated Utilization Management System (UMS) on admitted patients boarded in the Emergency and other units as required.
• Identify geriatric patients within the ED at high risk for admission, functional decline and revisit/readmission. Collaborate with primary care, LTC, community services and agencies in support of appropriate transition plan

Qualifications
Education:

• Registered Nurse with BScN required.
• Current Non Restrictive Licence in good standing from the College of Nurses of Ontario.
• Additional case management/leadership or geriatric certification / courses preferred.
• LEAN or process improvement education beneficial

Experience:

• Minimum 2 years of case management/discharge planning experience required
• Minimum 7years of recent clinical experience including leadership responsibilities required. Clinical experience with Geriatrics preferred
• Experience in organizing and leading interdisciplinary team and family case conference/discharge planning meetings with the principles of patient-focused model of care strongly required.
• Add experience working with community partners/agencies
• Knowledge and understanding of the application of relevant legislation (Health Care Consent Act, Substitute Decisions Act, etc.)

Competencies:

• Demonstrated knowledge and ability to lead case management/ discharge planning activities,
• Demonstrate effective interview skills as well as effective mediation/negotiation skills combined with the ability to work in collaboration with all members of the health care team both internally and externally across the continuum of care
• Ability to be self directed and thrive in a dynamic environment
• Demonstrates complex decision making skills, has the ability to organize, coordinate, problem solve, and communicate well with all professional groups,
• Demonstrated accurate and timely documentation, referral management and record keeping
• Demonstrated ability to work effectively with others, able to work both independently and as part of a team
• Demonstrated ability to set priorities and effectively resolve challenging situations that involved multiple stakeholders, patients and families
• Demonstrated understanding and competency of Alternate Level of Care (ALC), keep up to date on enhancements and changes to the WTIS reporting requirements for ALC
• Demonstrated knowledge and understanding of the legislation and Acts applicable to patient discharge and transition (ie Health Care Consent Act, Public Hospital Act, Substitute Decisions Act, Long term care act as relates to LTC application, Retirement Home Act, Mental Health Act)
• Demonstrated knowledge and understanding of consent and capacity and role of PGT/consent capacity board
• . .Quality improvement experience preferred
• Demonstrated excellent communication skills in English, both written and verbal.
• Demonstrated computer literacy.
• Demonstrated proficiency in using Medworxx UMS.

Other:

• Demonstrates commitment to continued professional and personal growth and development through Continuing Education Programs and Self Directed Learning Opportunities.
• Excellent work performance and attendance record required.

Our Employees Enjoy

• a professional practice environment
• a collaborative atmosphere with emphasis on teamwork
• wellness initiatives
• continuing education grants
• employee recognition and assistance programs
• a competitive salary and benefits package
• equal opportunities for growth and development

Employment Equity OSMH is committed to diversity and equity in the workplace and welcomes applications from all qualified individuals, including women, visible minorities, Indigenous peoples, persons with disabilities, LGBTQ2S persons and others who may contribute to a diverse workplace.
Accomodation in the Workplace Orillia Soldiers\xe2\x80\x99 Memorial Hospital is a respectful, caring, and inclusive workplace. We are committed to championing accessibility, diversity, equal opportunity and maintaining a barrier-free selection process for job applicants. Requests for accommodation can be made at any stage of the recruitment process providing the applicant has met the requirements for the open position. Applicants need to make their requirements known to the Human Resources department when contacted. All requests are handled confidentially.
Health & Safety Responsibilities OSMH is committed to providing a safe, healthy and supportive working environment by treating team members and patients with compassion accountability respect and engagement.

All team members must adhere to OSMH\xe2\x80\x99s Occupational Health and Safety policies, procedures and protocols, as well as the duties of workers as stipulated in the Occupational Health and Safety Act.

Team members must be able to perform all bona fide and essential duties of the position which may include cognitive and physical demands.

As a condition of employment, new employees are required to complete an employment health assessment and must be cleared by the Occupational Health and Safety Team prior to orientation.

As a condition of employment, you are required to submit proof of COVID-19 vaccination to the Hospital\'s Occupational Health and Safety department.
OSMH is a minimal fragrance workplace. We kindly ask all applicants to refrain from using scented products should they have the occasion to interview with the hospital. As a condition of employment OSMH requires professional references, verification of academic training, professional accreditation and evidence of course completion. It is also a condition of employment that all new employees will be required to present an original vulnerable sector check within 90 days of commencing employment and must sign an Offense Declaration upon receipt of an offer of employment.

If you are interested in joining our team, please apply online before 11:59 pm on the posting close date. Incomplete submissions will not be considered. We thank all applicants, however only those selected for an interview will be contacted.
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