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Home Care Nurses

Coordinated home care services assist individuals of all ages and their families to maximize their health and/or social well-being which allows them to remain in their own homes. In the larger communities, nurses are employed as home care nurses and work solely with the community home care program. In smaller communities, health and social services boards utilize their available community and regional resources.

Services include: case management, home nursing, personal care, assistance with activities of daily living, in home respite care, palliative care, rehabilitation, teaching and family support, meals on wheels, equipment loan coordination and foot care.

The goal of Home Care Nurses is to provide comprehensive Home Care services to residents of their respective community, in accordance with established standards of nursing practice, the philosophy, objectives, and policies of the Authority (and the principles of primary health care. The aim of this position is to protect and restore health of clients after acute illness, injury or surgery; to monitor and maintain health of clients with chronic illness; to provide palliative care; and to coordinate appropriate community based services for clients.

The Home Care Nurse reports directly to the Manager, Homecare and is assigned to one or more program teams (Wound Care, Palliative Care, Chronic Care, Foot Care, and Home IV Therapy). The incumbent independently makes six to eight home visits a day, and coordinates the care of 15 - 25 clients concurrently. It is the incumbent's responsibility to set priorities, develop work plans and manage workloads, while balancing each individual client's needs complexity and acuity.

The Home Care Nurse is a member of a multi-disciplinary team who provides direct care to clients, and acts as a client advocate, facilitating communication between the client, family and the physician, specialists and other health care professionals. This will result in a holistic approach to planning, organizing, teaching, and relationship development that will best meet the needs of the client.

Responsibilities

1. Provide comprehensive nursing care in the community setting that assists clients to achieve optimum health and quality of life in situations of chronic disease, acute illness, injury or through the process of dying. Care will be provided in one or more specialty areas, including wound care, palliative care, home intravenous therapy, or chronic illness.

2. Support the ongoing development, delivery, evaluation and improvement of Home Care programs and services.

3. Develop, facilitate, implement and modify health promotion activities based on the needs of the client.

4. Perform administrative functions that contribute to the effective functioning of the Home Care Program.

Common Duties of a Home Care Nurse

  • Make referrals to other health care professionals to ensure early diagnosis and prompt intervention
  • Coordinate the implementation of the care plan
    Assess the client and family's physical, emotional, intellectual and spiritual needs
  • Facilitate communication among client, family and other health care providers
  • Perform nursing interventions and transferred lab or medical functions
  • Fabricate or select devices or tools required to maintain independence at home
    Identify supports available to the client, such as community organizations, occupational therapy, mental health workers, etc.
  • Evaluate care on an ongoing basis to determine its effectiveness and appropriateness, and make changes as indicated
  • Maintain current expertise in one or more program areas, eg. wound care, palliative care
    Prescribe a treatment plan that incorporates the client's goals, needs, support systems, treatment and interventions, and resources required
  • Under the direction of the Manager, participate in interdisciplinary committees responsible for researching, developing and evaluating programs, including their associated forms, clinical policies and procedures
  • Research, develop, revise and evaluate educational resources necessary to support clients
  • Prepare and present information for in-service programs within the Homecare Department, YHSSA and other agencies in the community
  • Provide coaching, leadership and mentorship to peers, students and other members of the health care team
  • Orient new employees
    Determine the need for Home Care nursing services and admit or discharge the client as appropriate
  • Participate in meetings within the Department, YHSSA and with community organizations, as required
  • Enter statistical information into Health Suite in a timely manner
  • Maintain records related to hours worked, use of personal and office vehicles, services provided to clients without NWT Healthcare coverage, etc., as required
  • Collect and document demographic and statistical information
  • Act as Nurse-in-Charge during evening and weekend shifts (includes resolving staffing issues and functional supervision of Home Support Workers).