Palliative Care Coordinator - Couchiching Family Health Team (Orillia)

Job Description:

Position: Palliative Care Coordinator Nurse (1.0 FTE, contract, no benefits)
Reports To: Manager of Specialized Programs & Services

Position Summary

As a key member of the Couchiching Family Health Team (CFHT), and an integral part of an interdisciplinary health care team, you will deliver nursing care in accordance with FHT policies and professional practice standards. The Palliative Care Nurse is a specialist in palliative care and is responsible for the planning, coordination and delivery of palliative and end of life care to patients and their families and caregivers. Working in collaboration with an interdisciplinary team, the Palliative Care Nurse will provide clinical and educational support and facilitate care connections across the health care sectors for clients requiring palliative care in the community. As well, you will provide expert clinical palliative leadership to support seamless, integrated care delivery.

Roles and Responsibilities

• Screen, prioritize and process client referrals
• Consult with Primary Care Practitioners and specialists and review client clinical information obtained through the Primary Care Practitioner and client health records
• Provide client-centred case management, including assessment, service coordination, and evaluation, and a direct report to the Primary Care Practitioner, specialist involved in client’s care
• Link with community resources, particularly supportive care and palliative care facilities and services and share information to provide the best experience for the client
• In collaboration with the Primary Care Practitioner and other members of the interdisciplinary team, develop and discuss an appropriate individualized care plan with the client/family/caregiver based on best practice
• Recommend and teach client’s treatment protocols and education as required
• Liaise with other palliative care providers within the circle of care at palliative care rounds and provide home visits as required for integrated care delivery, adhering to the CFHT Home Visit Policy Guidelines
• Palliative pain assessment and management to assist Most Responsible Primary Care Practitioner (MRPCPs) with treating pain effectively in the palliative and end of life setting in the home. Suggest and support the MRPCP with appropriate directions in order to properly treat pain
• Indication to MRPCP what the patient’s current Palliative Performance Scale (PPS) is to alert the MRPCP to any changes that may need to be addressed to help improve Quality of Life (QOL)
• Implementing Edmonton Symptom Assessment Scale (ESAS) with every patient encounter to provide the MRPCP with an indication of what symptoms are paramount for the patient at any given time and assist the MRPCP with the appropriate treatment and avoid hospitalization
• Actively participate in staff, team and committee meetings, if appropriate
• Participate in the development, planning and evaluation of treatment, education, counselling and health promotion activities of the FHT
• Of note: Although it is not common practice for the CFHT palliative care coordinator to administer symptomatic medication to a patient, if the patient is exhibiting extreme symptoms that can be alleviated with medications available in the home, the CFHT palliative care nurse has the ability and is within the scope of practice to administer said medication according to the orders given by the MRPCP and chart the intervention accordingly
• Work in compliance with Health and Safety laws adhering to safe work practices and procedures established by the CFHT
• Other duties as required

Reporting

• Prepare quarterly reports and monitor daily statistical data to ensure statistics are reported to the Ministry of Health in a timely fashion
• Accurate and timely documentation into the Electronic Medical Record as per the CFHT Documentation Policy. Given the changing nature of health status within the Palliative Patient, however, priority must be given to recording details of sessions and documentation must be completed within 24 hours of the appointment.

Professional Development

• Maintain and develop professional competence through ongoing professional development
• Stay current and aware of opportunities to implement new, evidence-based methods of client assessment, treatment and programming
• Maintain and upgrade knowledge and skills
• Participate in clinical projects as required

Education/Specific Job Requirements:

• Baccalaureate degree in Nursing (or equivalent), Masters preferred
• Current Basic Cardiac Life Support
• Current membership with the College of Nurses of Ontario (CNO)
• Current membership in Registered Nurses Association of Ontario (RNAO) preferred
• Demonstrated understanding of client-centred case management, including assessment, service coordination, and evaluation
• Demonstrated and comprehensive understanding of ethical decision-making principles, palliative care philosophy, and quality end of life care planning
• Demonstrated working knowledge of community resources, particularly supportive care and palliative care facilities and services
• Demonstrated evidence of sound organizational, prioritization, and conflict management skills with the ability to work well in stressful situations
• Excellent communication, negotiation, teaching and interpersonal skills with the ability to work well with patients, families, all levels of staff and the community
• Demonstrated ability to work well autonomously
• Maintain confidentiality in accordance with the Municipal Freedom of Information and Protection of Privacy Act
• Flexible to meet additional responsibilities as program demands
• Positive attendance and work record essential
• Able to work flexible hours including evenings if required
• Police Record/Vulnerable Sector Check
• It is a condition of employment that you receive the necessary vaccinations to protect against infection of COVID-19, or any similar infectious diseases, which may be recommended by governmental and public health authorities from time to time

Experience:

• Demonstrated clinical competence in nursing practice with 3-5 years recent experience working in a palliative care/oncology/hospice environment. Preference will be given to those candidates with foundations in oncology courses and CNA Palliative/Hospice Care certification
• Highly experienced with physical assessment as well as competence in emotional assessment to assist MRPCP with developing an appropriate plan of care as per patient wishes