About this role
Summary
JOB SUMMARY: Within the context of a patient, client and family centred model of care and, in accordance with the Mission, Vision and Values, and strategic directions of Providence Health Care, promotes a safe, respectful, and civil working environment for patients, residents, families, visitors and staff. Reporting to the Patient Care Manager, the Geriatric Outreach Nurse, works as part of an interdisciplinary team to provide outreach services to seniors. Receives referrals related to complex patient care issues, conducts geriatric nursing assessments, connects patients with community services and supports ongoing care and transition. Develops, implements, and adjusts individualized treatment plans in collaboration with team members and monitors outcome of care. Role models best practice direct care skills in the assessment and case management of patients. Leads and/or participates in team case conferences/meetings to coordinate and manage patient care issues. Coordinates patients’ access to needed services and establishes and maintains effective working relationships with staff within the emergency rooms, inpatient units, and other resources. Develops, implements, and evaluates patient and staff education programs and education materials. Participates in team meetings and quality improvement activities.
QUALIFICATIONS: Education, Training, and ExperienceCurrent practicing licensure as a Registered Nurse or a practicing Registered Psychiatric Nurse with the British Columbia College of Nurses and Midwives (BCCNM). Three (3) years’ recent, related experience in geriatric nursing and completion of the Canadian Nurses Association (CNA) specialized Gerontological Nursing Certification (GNC[C]) or a post graduate specialty program in geriatric nursing or an equivalent combination of education, training, and experience. Local area travel requires the use of a personal vehicle. Valid BC Drivers License.Skills and Abilities• Demonstrated knowledge of evidenced-based nursing practice relating to geriatrics including issues associated with aging, chronic illness and psychosocial factors such as caregiver issues, family dynamics, and communication patterns.• Demonstrated knowledge and ability to perform Cardiopulmonary Resuscitation (CPR) procedures appropriate for the area of service.• Demonstrated knowledge of psychopharmacology (indication and side effects).• Demonstrated knowledge of hospital and community-based resources and referral options and the ability to function as a liaison between services.• Demonstrated ability to provide treatment planning, counselling, crisis intervention, and case coordination.• Demonstrated ability to problem solve using sound judgement, critical thinking, communication, and interpersonal skills.• Demonstrated ability to coach and counsel patients, families and staff.• Demonstrated ability to identify learning needs and develop educational programs.• Demonstrated ability to role model evidence based geriatric nursing practice.• Demonstrated ability to work as a member of an interdisciplinary team.• Demonstrated ability to communicate effectively both verbally and in writing.• Demonstrated ability to role model conflict resolution strategies and manage aggressive behaviours.• Demonstrated ability to prioritize and organize work independently.• Knowledge of research processes and methodology. • Physical ability to perform the duties of the position.• Demonstrated ability to operate related equipment, including computers.1. Provides outreach services to geriatric using a case management approach by receiving and responding to referrals from inpatient units, family physicians, community agencies, and/or other resources. Reviews referral information and gathers patient information/history, seeks additional information as needed.2. Evaluates overall patient needs in order to implement or revise treatment plan. Identifies priority of service required, assesses high-risk situations and provides crisis intervention as required. Meets with patients in various locations such as emergency rooms, inpatient units, and places of residence and provides patient counselling services. Seeks input and collaborating with interdisciplinary team members to ensure optimal plan of care is implemented.3. Develops, implements, and evaluates patient care plan and provides appropriate education and support to patient and families. Teaches patient and/or significant other(s) self-care management and how to administer treatments and operate equipment safely both at home and/or in the hospital.4. Leads and/or participates in case conferences and meetings with patients, families and care providers to discuss management of patient care issues. Determines families understanding of patient’s discharge clinical care needs and identifies concerns regarding services and ongoing follow up care requirements.5. Contacts patient before and upon discharge using patient’s social/family/caregiver network to follow up on self care management and transition plans. Ensures patient attends follow up appointments with other health care professionals and ensures patient understands medication regime and treatment plan. Participates in the assessment, implementation and evaluation of medication and treatment plans through ongoing dialogue with patients, caregivers, physicians, pharmacists, etc. Assesses if follow up visits are required.6. Coordinates the linkage of patients with community services/programs/resources by liaising and communicating with a range of health care professionals to ensure support structures are in place to meet patients’ care needs through the transition process to home or other placement.7. Observes patient/family/caregiver interactions, identifies cases of abuse or neglect and refers to appropriate resources when needed.8. Liaises with staff of Emergency Departments, BC Ambulance, Vancouver Police Department, and other community-based resources in the coordination of services and follow up for seniors. 9. Provides formal consultations and acts as an education resource to staff/community nurses and other healthcare providers by providing specialized knowledge/guidance in the management of complex care issues. 10. Provides protocols, procedures and other resources to community-based care providers and home support services to direct the care of patients and ensure optimal care. Demonstrates procedures, answers questions related to clinical practice issues and/or complex patient care situations, problem solves and troubleshoots concerns.11. Works with Patient Care Manager to coordinate program activities and develop and revise program standards, practices, policies, and procedures. Develop proposals and new programs, as required, to meet staff and patient learning needs, coordinates and schedules educational activities, identifies outcome indicators and evaluates and revises programs accordingly.12. Prepares and maintains patient records by documenting patient assessments and interventions in accordance with established standards, policies, and procedures to meet regulatory requirements, and provide evidence and rationale that supports conclusions and intervention plan.13. Advocates for patient when they are unable to do so for themselves.14. Organizes resources, supplies and equipment for patient/family home as required. Develops educational materials for patient/family and community services, such as pamphlets, brochures, instruction sheets, and manuals.15. Promotes the use of research findings into practice by incorporating information into policies, procedures, reference materials, education materials and teaching session.16. Supports research activities and coordinates and/or participates in the development of quality improvement initiatives by participating in ongoing qualitative and quantitative research projects and ensuring ongoing patient satisfaction measurement.17. Identifies trends in patient outcomes and recommends program modifications tothe Patient Care Manager.18. Represents the program/service hospital and community committees as requested, maintaining liaison with external agencies. Reports back to program/service.19. Performs other related duties as assigned.
## Please Note
If you are the successful applicant, you will have 48 hours to accept or decline the offer. You will assume all responsibility for ensuring your contact information is accurate and for being informed during the 48 hour acceptance window. If there’s no response, the offer will be automatically withdrawn and the manager will move to the next candidate.
## Article Flag
NBA regular posting
## Job Accuracy Posting Flag
The hours of work, including start and stop times, days off, work area and work site may be subject to change consistent with operations requirements and applicable provisions of the Collective Agreement and statutes. **Testing may be required. ***A criminal record check may be required
## Minimum Nurse-to-Patient Ratio
Minimum Nurse-to-Patient Ratios (mNPR) set the minimum number of nurses required to safely care for patients on a given unit. Developed in partnership with the Ministry of Health, the BC Nurses' Union (BCNU), and health organizations across British Columbia, mNPR provides a consistent and transparent approach to staffing that supports safe nursing practice and high-quality patient care. At Providence Health Care (PHC), our approach to implementing mNPR reflects our commitment to person-centred, socially just, compassionate care and our dedication to Indigenous cultural safety. Guided by our mission and values - Spirituality, Integrity, Stewardship, Trust, Excellence, and Respect - PHC is working collaboratively across all departments to ensure mNPR is thoughtfully adapted to the unique needs of each clinical program and specialty area. This tailored, values-driven implementation aligns with our commitment to compassionate, innovative, and patient-centred care and positions PHC to meet the evolving health needs of our patients, residents, families, and communities.