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About The Position
Calgary Foothills Primary Care Network (PCN) is a group of family physicians and health care professionals in northwest Calgary and Cochrane collaborating with various external stakeholders to deliver the best possible primary care. The PCN has established a team environment where individuals are encouraged to take initiative, be creative and contribute to ongoing decision-making.
The PCN’s Extended Health Team (EHT) is comprised of registered nurses, clinical pharmacists, kinesiologist, occupational therapists, physical therapists, social workers, family physicians, nurse practitioners and mental health consultants. The team helps patients with complex chronic health conditions who struggle with psychosocial factors to self-manage chronic conditions, set achievable goals and access additional resources and support. Group and individual appointments or home visits are tailored to the patient’s needs.
Reporting to the Program Manager, the Registered Nurse collaborates with the family physician, PCN multidisciplinary teams and community/external partners to provide patient-centered care for those with chronic disease and/or complex health conditions.
Requirements
- Understanding regarding nursing scope of practice within community setting
- Experience as a case manager
- Expertise in active listening and motivational interviewing
- Excellent communication (written and verbal), organization and critical thinking skills
- Strong skills in collaborating with team members and physicians
- Maintains an individual’s dignity and self-worth during all interactions
- Excellent group facilitation skills
- Ability to provide evidence-based care
- Ability to work well in a team setting and independently
- Excellent computer skills are required
- Strong health assessment and documentation skills
- Ability to prioritize, manage time effectively and be flexible in a very dynamic work environment
- Ability to work flexible hours, including evenings/weekends, when required
- Accepts, implements and evaluates change with a positive attitude
- Graduate of an accredited diploma and/or degree program in nursing
- Licensed with the College of Registered Nurses of Alberta as a practicing member
- Must possess a valid driver’s license and have access to a vehicle
- MoCA certification required
- Completion of a satisfactory criminal record check and/or Vulnerable Sector Search.
Nice To Haves
- Experience with trauma informed care an asset
Responsibilities
- Working with patients on self-management by providing coaching and education to help advance their skills, knowledge and self-efficacy in adopting healthy lifestyle behaviours that are meaningful to them
- Helping to build care plans with patients who have, or are at risk of, chronic health conditions through biopsychosocial health assessment, collaborative goal setting, applicable interventions based on patient readiness, regular follow-up, and evaluation of progress
- Conducting cognitive assessments in a team based approach, which may include cognitive screening of patient and/or collateral history gathering
- Supporting the navigation of the health care system to connect patients and the medical home to applicable PCN, community and health system resources as needed
- Promoting continuity of patient care through effective written and verbal communication with the Patient’s Medical Home and those involved in the circle of care
- Building relationships and developing the Registered Nurse role within and outside of the PCN
- Providing care through individual and facilitated group appointments, which may include home visits
- Consulting with hospital, community and other PCN health care providers to ensure seamless care transitions
- Participating in the development, delivery, evaluation and quality improvement of health programs and evidence-based practice
- Collecting and maintaining data for service indicators, progress reports and evaluations
- Adhering to and performing activities and care within the full scope of practice as defined under the Health Professions Act
