Transition Services Coordinator (Nursing)

Description

JOB SUMMARY:Within the context of a client and family centred care model and in accordance with the British Columbia College of Nurses and Midwives (BCCNM) Nursing Professionals (BCCNP) standards of professional practice and Code of Ethics for registered nurses or registered psychiatric nurses, and the established vision and values of the organization, the Transition Services Coordinator leads and facilitates 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. Responsible and accountable for the development and effectiveness of policies, procedures and standards for the transition services program in community care. Coaches and encourages acute and community colleagues to embrace new and evolving clinical pathways and practice (Home is Best). Plans and facilitates clinical discussions to support safe client discharges with care teams and other health care professionals; advises on the availability and eligibility for community services. Makes community referrals based on client needs, urgency and best practices to determine the appropriate treatment; educates and provides consultation to client/family. Coordinates transition of clients to residential care, utilizing clinical decision support tools (Inter-RAI MDS) as appropriate. Documents and maintains client records and clinical assessments. Participates on committees as directed. Coordinates 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. Assists 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 & AbilitiesBroad 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.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.

Details

At Vancouver Coastal Health, our vision of healthy lives in healthy communities inspires us and our values and pillars guide us. We support equitable practices, diverse teams and inclusive environments, which are vital to creating welcoming spaces where everyone can bring their whole selves to work and feel supported. We encourage applications from equity-deserving communities, including Indigenous Peoples and members of racialized groups, people with disabilities and people of all gender identities and expressions and sexual orientation.Vancouver Coastal Health is proud to be recognized as one of BC’s Top Employers, Canada’s Best Diversity Employers and Canada's Top Employers for Young People in 2025.Unless otherwise noted on the posting, internal job postings close at 8:00 AM Pacific Time on the listed Closing Date. Please submit your digital application via the Internal Career Portal prior to the Closing Date & Time.Nursing & LPN successful applicants will be notified by email.We regret that only short listed candidates will be acknowledged.This is an internal job posting for Vancouver Coastal Health employees only.