Vancouver Coastal Health

As a Transition Services Coordinator with VCH, you will:
Lead and facilitate acute to community transitions by assessing and evaluating clinical and functional need and coordinating community staff/resources in carrying out the care following discharge from an acute site.
Be responsible and accountable for the development and effectiveness of policies, procedures and standards for the transition services program in community care.
Coach and encourage acute and community colleagues to embrace new and evolving clinical pathways and practice (Home is Best).
Plan and facilitate clinical discussions to support safe client discharges with care teams and other health care professionals; advise on the availability and eligibility for community services.
Make community referrals based on client needs, urgency and best practices to determine the appropriate treatment; educate and provide consultation to the client/family.
Coordinate transition of clients to long term care, utilizing clinical decision support tools (Inter-RAI MDS) as appropriate.
Document and maintain client records and clinical assessments.
Participate on committees as directed.
Coordinate care given by others in an area or unit by way of assigning service priority to various Home Health teams and making/adjusting client/patient/resident assignments.
Assist in administrative activities and optimal use of program resources.
Qualifications:
Education Experience
Current practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives (BCCNM).
Five (5) years’ recent, related experience which includes three (3) years in a community health setting, one (1) year experience in quality improvement, research and evaluation activities, and a clinical decision-support tool for severity assessment and discharge (Acute/Subacute/SNF/Rehabilitation/Behavioural Health), experience in a tertiary health care environment, or an equivalent combination of education, training and experience.
Knowledge, Skills Abilities
Broad knowledge of nursing theory and practice within a client and family centred model of care.
Broad knowledge of the BCCNM Standards for Nursing Practice.
Broad knowledge of evidence based nursing practice related to patient acuity and bed utilization practices within a tertiary level teaching hospital.
Broad knowledge of other health care disciplines and their role in client care and discharge planning.
Broad knowledge of clinical studies methodology and data presentation.
Demonstrated ability to apply critical thinking within clinical and evaluation activities.
Demonstrated ability to work independently.
Demonstrated ability to work collaboratively as a member of an interdisciplinary team.
Demonstrated ability to demonstrate, facilitate and coach.
Demonstrated ability to communicate orally and in writing.
Demonstrated ability to communicate with, and deal effectively with, co-workers, physicians, other health care staff, clients and their families, and staff of outside agencies.
Demonstrated ability to effectively deal with conflict situations.
Demonstrated ability to adjust to new or unexpected events.
Demonstrated ability to plan, organize and prioritize work.
Demonstrated physical ability to perform the duties of the position.
Demonstrated computerized software skills in word processing, databases, spreadsheets, presentations and internet access and ability to operate a computerized patient care information system.
Ability to operate related equipment.
Closing Statement:
The hours of work including days off and work area may be subject to change consistent with operational requirements and the provision of the Collective Agreement and applicable statutes.

As per Ministry of Health policy, all health care workers working in publicly-funded health care facilities are required to report their past receipt of certain vaccines or history of certain infections. Collecting these records will allow for offering of any missing vaccines, and for appropriate actions to be taken in the event of any future exposure to a communicable disease or during outbreaks. For all new hires and appointments to Vancouver Coastal Health, you will be asked to provide this information as part of the onboarding process. Read more