As a Nurse Practitioner within our Integrated Palliative Home Care Program, you will create a direct link between the home care team and the primary care practitioners to increase capacity in the community for end-of-life care. In addition to palliative clients with stable and predictable needs, you will serve a population of clients with complex medical, physical, cognitive and psychosocial conditions that place the client at risk for avoidable hospitalization, premature institutionalization or Alternate Levels of Care (ALC).
Your focus will be on providing critical capacity to enhance continuity of clinical care coordination across primary care, home care, community supports, acute and specialty palliative care sectors. This will see you working collaboratively across the health care system, providing expert clinical palliative leadership to support seamless, integrated care delivery. In your leadership role as a Palliative Care Nurse Practitioner, you’ll have the opportunity to engage in all domains of advanced practice nursing, including mentoring and professional development through coaching for Care Coordinators, service providers, nursing and physician colleagues, and participating in educational initiatives to advance evidence-based practice in palliative care.
Location: This position will involve regular travel across the Home and Community Care Support Services for meetings and home visits; as a result, a valid driver’s licence and access to a reliable vehicle are required.
As a Palliative Care Nurse Practitioner, you will play a critical role as part of an interdisciplinary team, where your broad scope of practice will support collaborative practice across the health care continuum. Specifically, you can expect to:
- Ensure rapid response capacity to provide expert clinical care to complex palliative clients and expert clinical advice to primary care physicians, community nurses on the management of pain and symptoms, psychosocial support and therapeutic interventions.
- Make home visits to complex palliative clients and their families, to complete comprehensive clinical assessments and contribute to the development of comprehensive shared care plans in consultation with Home and Community Care- Care Coordinators, service providers, primary care physicians and others.
- Provide direct clinical care by visiting patients at home to: ◦obtain consent for treatment
◦conduct advanced clinical assessments
◦provide diagnosis of disease
◦perform intervention based on NP scope of practice
◦manage disease-specific pain and symptoms
◦sign the Certificate of Death
- Act as the lead and clinical expert to the Care Coordinator in terms of professional practice and clinical expertise in the development of palliative care plans for complex clients (shared care plans) and chronic clients (coordinated care plans) that balance clinical, system and family needs.
- Be a professional practice lead and provide clinical expertise to nurses and Care Coordinators, as necessary.
- Provide consistent clinical support for chronic palliative clients and their families, as the clients interact with home and community care, primary care, acute care, and specialist care.
- Participate in client rounds and case conferences with palliative care teams.
- Develop a shared care partnership with primary care, and support primary care physicians in caring for palliative clients on their roster.
- Coordinate access to specialized palliative care and, when needed, acute services, including providing advice and support to ensure safe and seamless transitions between care settings.
- Facilitate ongoing integration of client’s medical care (especially pain and symptom management) across the health care sector to ensure all domains of palliative care are addressed in a seamless, integrated manner and client and family goals are achieved.
- In case of palliative client hospitalization, arrange with the Care Coordinator the enhanced home care supports and services to permit a safe transfer back to the home.
- Ensure regular communication with the direct care community team and the primary care physician for each palliative client.
- Participate in regular business meetings to assist in program development and ongoing monitoring and evaluation.
- Participate in systems planning and system integration activities with the goal of ensuring a comprehensive, high-quality system of hospice palliative care.
- Act as a spokesperson, as required, and ensure positive public relations and effective coordination of services through ongoing liaison and participation on internal and external committees.
- Initiate, benchmark, recommend, implement and evaluate best practices in the delivery of palliative care services.
- Identify, assess and meet the educational needs of clients, their families and other informal caregivers.
- Participate in identifying the educational needs of the interdisciplinary care team and facilitate or participate in the provision of education to meet those needs.
- Provide leadership and role modeling in critical thinking, problem-solving, ethical decision-making and use of evidence to inform service planning and system design.
- Remain current with evidence-based palliative care literature, including best practice guidelines.
- Assess for, and promote, a safe environment for clients, caregivers, family members, and staff, while ensuring adherence to Home and Community Care Support Sevices Central's health and safety policies and practices.
- Participate in committees and workgroups, as required.
Your professional strengths for the role of Nurse Practitioner – Palliative will include:
- Current registration with the College of Nurses of Ontario in the Extended Class
- Completion of the Nurse Practitioner Program with a BScN (master’s level degree in Nursing preferred)
- Canadian Nursing Association Certification in Hospice Palliative Care or relevant specialty certification
- From 2 to 5 years’ experience, preferably in a community setting and in Palliative Care Nursing
- Experience as a Nurse Practitioner, preferred
- Demonstrated experience with proven team-building abilities and experience in advancing the clinical practice of multiple health disciplines
- Demonstrated expertise in advanced clinical practice of multiple health disciplines
- Demonstrated advanced knowledge in consultation and ethical decision-making
- Demonstrated experience using theory and evidence to advance clinical practice and outcomes
- Knowledge of the principles of adult education
- Working knowledge of community resources and roles of health care professionals
- Solid knowledge of health care related legislation and practices
- Knowledge of direct care/case management models used in community health care organizations.
- Knowledge of LHIN priorities, policies, practices and service standards
- Effective interpersonal, communication, organizational and planning skills
- Basic proficiency with computerized information systems
- A demonstrated commitment to the Home and Community Care Support Services Central’s mission and values
- Ability to effectively maintain a constant flow of verbal and written communication with others throughout the workplace as well as outside the organization
- Excellent coaching, facilitation, critical thinking and problem-solving skills
- Ability to communicate with clients, their families, health care providers and other relevant individuals in order to follow through with care plan directives
- Demonstrated awareness of cultural diversity and the ability to handle confidential issues discreetly and sensitively
- Skill in building professional relationships across the health sectors
- Ability to research, analyze and evaluate hospice palliative care best practices program development and implementation.
- Bilingualism considered an asset.