Program Overview
The Eastern York Region North Durham (EYRND) Ontario Health Team (OHT) launched the Seniors Home Support (SHS) Program in 2021, an integrated primary care team serving frail, homebound seniors in the communities of Markham and Stouffville.
The program serves a roster of more than 300 patients who experience physical, cognitive, and social barriers to attending office-based care. Through its current model of care, patients receive longitudinal primary care, including routine and urgent home visits, virtual care, and palliative care. Improving access to in-home primary care is critical for this population: 50% live with significant cognitive impairment, 26% have a history of stroke, and 27% live with moderate to severe heart failure.
The interprofessional team includes family physicians, a nurse practitioner, a pharmacist, a chiropodist, registered nurses, community paramedics, and home care coordinators from partner organizations, including Markham Family Health Team (FHT), Markham Stouffville Hospital (MSH), York Region Paramedic Services Community Paramedicine Program, and Ontario Health atHome. The SHS program is one of Ontario’s few home-based primary care programs that integrate community paramedics as part of the core care team.
For more information about the SHS program, please visit: https://www.eyrnd.ca/seniors-home-support
Position:
We are presently seeking an enthusiastic individual to join our high functioning interprofessional team as a full-time Nurse Navigator.
Reporting to the Executive Director, the incumbent will work within our Seniors Home Support Program serving the primary care needs of homebound seniors. The Nurse Navigator is the primary point of contact through the patient care journey and is responsible for providing expert clinical telephone triage and navigational support to rostered patients and their caregivers.
Qualifications/Skills
- BSCN preferred, or evidence of working towards
- Current registration with the Ontario College of Nurses
- Experience working with geriatrics patients with complex medical needs strongly preferred
- Experience and knowledge of existing programs and services within Markham and Stouffville is an asset
- Experience working within an interprofessional team environment as well as independently and autonomously with efficiency
- Excellent interpersonal and decision-making skills - strong organizational skills
- Ability to adapt to a changing environment and assume responsibility for own learning
- Demonstrated leadership skills and ability
- Computer literacy required; experience with Meditech and Accuro an asset
Responsibilities:
- Triage and respond to patient concerns on a daily basis
- Liaise with physicians, NP, interprofessional team, community paramedics and home and community care providers to action and modify clinical plans as required
- Support SHS referrals or urgent clinical referrals as needed
- Relay relevant patient messages to most responsible practitioner (MRP)/interprofessional team
- Fill out appropriate referral forms to community programs (i.e. palliative team, LTC, behavioural support services, etc.) and follow-up to ensure warm transfer
- Support and navigate both patients and their caregivers with access to appropriate community support services
- Advocate, navigate and facilitate access to resources
- Check emails for notifications for ED/inpatient patient admissions
- Meet clients and their caregivers in ED/hospital as needed. If unable to meet in person, connect with ED clinical team to ensure warm handover
- Work collaboratively with hospital patient flow coordinators to inform them about patients and their transfer to community programs
- Provide urgent telephone follow-up to patients (e.g. follow-up for key incomplete tests, close monitoring of unwell patients recently started on antibiotics at home, follow-up fluid overloaded patients). Close communication loop and provide updates to MRP
- Manage routine medical-related concerns (pharmacy clarifications, missing lab requisitions, IV antibiotics, flu shot questions, and outstanding tests)
- Participate in use of tracking codes in Accuro to document work for KPI/QI purposes
- Document all patient interactions on Accuro; complete clinical notes in Accuro within 24h
- Attend team meetings regarding program operations, planning, and evaluation
- Provide cross-coverage for team coordinator or other team members as needed
Pay: $72,000.00-$75,000.00 per year
Benefits:
- Casual dress
- Company pension
- Dental care
- Extended health care
- Life insurance
- On-site parking
- Vision care
Work Location: Hybrid remote in Markham, ON
