Registered Nurse, Geriatric Outreach Team- Couchiching Family Health Team (Orillia)

Job Description:

Couchiching Family Health Team

Position: Permanent Full-Time (2.0 FTE) Registered Nurse – Geriatric Outreach Team
Reports To: Team Lead—Complex Care Team
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 Geriatric Nurse is a specialist in geriatric care and is responsible for the planning, coordination and delivery of services to patients who are seniors and their families and caregivers. Working in collaboration with an interdisciplinary team, the Geriatric Nurse will share expertise and knowledge of health promotion and disease prevention, helping to connect patients with appropriate services and professionals.

Roles and Responsibilities:

Assessment:

• Screen, prioritize and process client referrals to the designated program
• Review client clinical information obtained through the physician or IHP referral, laboratory results and health records
• Conduct consultations with clients/family to obtain relevant information and assess client/family learning’s and needs
• Conduct home visits
• Complete Comprehensive Geriatric Assessments (CGA’s)
• Complete Coordinated Care Plans for clients in the program

Planning:

• In collaboration with the Family Physician and other members of the interdisciplinary team, develop and discuss appropriate individualized care plan with the client/family/caregiver based on best practices
• Partner with community resources in developing goals and objectives and help guide the family and client to the necessary services available
• Provide ongoing case management for patients identified as at risk and enrolled in the geriatric program
• Collaborate with the Geriatrician to deliver effective primary care
• Recommend and teach client’s treatment protocols and education as required
• Document all health notes into the EMR daily and arrange necessary follow up

Reporting:

• The Geriatric RN will report directly to the Team Lead, Complex Care Team
• Prepare monthly statistical reports to be submitted to Ontario Health as needed

Team Development:

• Work effectively within an interdisciplinary team
• Promote awareness of the FHT’s program and services
• 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

Professional Development:

• Maintain and develop professional competence through ongoing professional development
• Fully participate in the Quality Assurance Program of the College of Nurses of Ontario
• Stay current and aware of opportunities to implement new, evidenced based methods of client assessment, treatment, and programming
• Participate in clinical projects as required
   

Skills/Knowledge Requirements: 

• Team player, demonstrated ability to engage in truly collaborative practice with Interprofessional colleagues both across the FHT, multidisciplinary members and the physician office teams
• Superior leadership, organization, evaluation, time management, communication, and interpersonal skills
• Proficiency in the use of computer hardware and software, particularly in Microsoft word, excel, outlook and electronic medical records
• Works in compliance with Health and Safety laws adhering to safe work practices and procedures established by the CFHT 
• Excellent verbal and written communication
• Demonstrated ability to work well autonomously
• Adaptable to change
• Knowledge in current, evidence-based methods and practice of primary care delivery
• Excellent oral/written/interpersonal skills
• Other duties as required
   

Education/Specific Job Requirements:

• Baccalaureate of Science in Nursing required
• Current registration with the CNO
• Gerontological Nursing Certification preferred
• Current membership with the RNAO preferred
• Basic CPR
• Current Ontario Driver’s License and access to reliable vehicle for travel to various communities
• Provide evidence of a clean driver abstract and proof of insurance 
• Able to work flexible hours including evenings if required
• Police Record/Vulnerable Record 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: 

• Minimum 5 years experience in a community and/or Primary Health Care setting with a focus on geriatric care