POSTING # ESC 008/16
JOB TITLE: Full-Time Rapid Response Nurse – Sarnia
LOCATION: Erie St. Clair Community Care Access Centre; Travel for this position is required between all sites of the Erie St. Clair CCAC
SUPERVISOR: Patient Services Manager
Reporting to the Patient Services Manager, the Rapid Response Nurse is responsible for providing a "hands-on" and an "in-home" support approach for successful transition from the acute care setting (hospital) to home (community). The Rapid Response Nurse will provide patients with timely communication and linkage to primary care.
As an integral part of an interdisciplinary team, the Rapid Response Nurse will ensure effective transitions from acute care settings to home for two primary target populations: medically complex children and frail adults and seniors with complex needs and/or high risk characteristics (e.g. congestive heart failure) with the expected outcome of reducing re-hospitalization and/or Emergency Room (ER) visits.
The Rapid Response Nurse provides the first in-home nursing visit within 24 hours from hospital discharge for these identified populations. During this visit, the nurse confirms the patient hospital discharge care plan, assesses any other needs, communicates the importance of primary care to avoid re-hospitalization and performs medication reconciliation for the patient. There may be opportunity in future to use technological and/or telemedicine techniques to further meet the needs of these patients.
NATURE & SCOPE:
- Review discharge care plans and confirm outstanding medical tests have been scheduled and transportation is available
- Ensure new prescriptions are filled and conduct medication reconciliation to confirm no drug interactions or contraindications. Review medication protocol with patient and caregiver and answer any questions
- Initiate contact with primary care physician and provide an update on patient acute care event and post-discharge regime. Appropriately recommend and facilitate a one-week patient follow-up visit with the primary care physician
- Provide direct clinical assessment and care to patients
- Identify patients requiring an accelerated assessment and home care services and work with the Care Coordinator to facilitate the home assessment visit
- Inform and support the Care Coordinator in developing the patient's care plan and ensure a smooth transfer of the primary care physician and pharmacist to the ongoing care team
- Answer any questions or concerns of the patient and caregiver, respecting the patient's ethnic, spiritual, linguistic, familial and cultural differences and provide CCAC phone number for support
- Assess and promote a safe environment for patients, caregivers, family members, and staff.
- Adhere to policies and practices developed and implemented by the CCAC
- Share information according to privacy guidelines
- Participate in establishing, maintaining, and monitoring standards for case management. This includes committee work and active participation and contribution to quality and educational initiatives
- Participates in events to promote CCAC objectives, activities, programs and services
- Works effectively with superiors and colleagues to deliver effective and efficient patient service delivery