Registered Nurse/Case Manager – Bridgepoint FHT (Toronto)

POSITION:                             Registered Nurse/Case Manager (1.0 FTE – 1 year contract) REPORTS TO:                      Executive Director, Bridgepoint Family Health Team DATE PREPARED:              December, 2013 POSITION SUMMARY This Coordinated Care Plan Initiative is a major project for the Don Valley Greenwood Health Link (DVGHL) to improve care coordination for those living in our community with complex chronic health issues. WoodGreen is the coordinating agency for the Don Valley/Greenwood Health Link and Bridgepoint Family Health Team (BFHT) is one of its partners. This position will be based at the BFHT and collaborate with all partners within the DVGHL. This position will have significant interactions with multiple partners and agencies. Strong relational, clinical, and organizational skills are a central function of the position. The primary role is to work in partnership with multiple health disciplines to develop and implement a coordinated care plan with complex patients. The process for the coordinated care planning will include multi-disciplinary case conferences, home visits as required, vigorous follow-up to implement the care plan, and patient education/follow-up. CORE RESPONSIBILITIES
  1. Develops strong working relationships with the clinical teams in each of the partner agencies working on the coordinated care plan project.
  2. Assists with the administrative preparation for coordinated care planning activities, such as case conferences and/or multidisciplinary clinics.
  3. Fosters a respectful relationship with the client to facilitate the development of the coordinated care plan.
  4. Performs comprehensive and focused patient health assessments that include a health history and thorough physical evaluation, when necessary. Evaluation includes psychosocial, emotional, ethnic, cultural and spiritual dimensions of health.
  5. Documents all client related communications accurately and in a timely manner. Adheres to confidentiality and privacy practices and policies.
  6. Engages in home visits with patients as required by the care team.
  7. Follows-up with the patient  following the development of the coordinated care plan to ensure activities agreed upon are completed or alterations made to the care plan as required and agreed to by the care team.
  8. Participates in the ongoing evaluation of the care plan tool and processes involved in the development of the care plan.  Provides feedback and advice to the DVGHL working group on how to improve the processes and tools.
  9. Understands how telemedicine may be used to facilitate the care planning process and assists to arrange this as needed.
  10. Participates on the coordinated care plan working group of the DVGHL.
  • A member in good standing registered with the College of Nurses of Ontario
  • Baccalaureate degree in Nursing.
  • Basic CPR certification
  • Knowledge and a demonstrated nursing ability in community health, public health, and chronic disease management. Minimum five years experience preferable
  • Demonstrated ability to work collaboratively and foster positive relationships with a broad spectrum of people
  • Proven experience working independently and in teams.
  • Ability to implement program plans, prioritize work and achieve successful results
  • Proven capacity to foster innovation and creativity and a spirit of excellence
  • Enthusiasm for learning and demonstrated efforts to continuously develop and upgrade skills
  • Highly effective oral and written communication skills.
  • Sensitive to working with people of diverse cultural, age and economic backgrounds and marginalized individuals.
  • Ability to exercise good judgment, flexibility, creativity and sensitivity in response to changing situations and needs.
Please submit a cover letter and CV, in confidence, to Shantelle Veld at by 5pm on Jan 21, 2014. Please note only successful candidates will be contacted.