Advanced Practice Nurse - Family Practice Health Centre

Women's College Hospital - Toronto, ON (30+ days ago)

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Women’s College Hospital is the first and only independent, academic, ambulatory care hospital in Ontario with a primary focus on the health of women. If you’re ready to be part of the future of healthcare, then you will want to join an institution in which the possibilities for creative innovation, breakthroughs in new thinking and groundbreaking work in academic ambulatory medicine are limitless. Women’s College Hospital is committed to patient safety as a key professional value and an essential component of daily practice.

The Advanced Practice Nurse in Family Practice acts as the primary clinical point of contact for Family Practice patients and provides comprehensive and proactive assessment and care planning for patients within a primary care setting. The Advanced Practice Nurse will demonstrate leadership in the development, planning, implementation and evaluation of the WCH Family Practice programs utilizing an interprofessional, collaborative approach.

Summary of duties, but not limited to :
The APN ensures that a consistent, high quality, and evidence-based approach is used to provide patient care. Patients will receive care that is coordinated and navigated along the patient care path ensuring all information is available to them, their caregivers, and family members in a timely manner.
Proactively coordinates care delivery and supports for family practice patients and acts as primary source of contact for patients and families/support person.
Responsible for the assessment of patients’ physical, social, and psychological needs; counsels, and educates family practice patients
Partners with patient and families and/or supports, and other health care team members to provide continuity of care through the health care system

Maintain the medical record alert system to recall patients for health promotion and disease prevention follow-up such as pap smears, mammograms, FOB testing, hypertension, and diabetes care.
Perform panel management for subset of patients. Assess patient health care needs, discuss test results and respond to questions pertaining to health promotion and disease prevention. Redirect calls to booking when necessary.
Facilitates internal or external referrals and partners with community and hospital based clinics to support and improve access to care
Liaises with community agencies/social supports to ensure patients in community are receiving appropriate care and follow up; intervenes to address concerns when required

Provide an educational role to patients, caregivers, families and colleagues in an environment that facilitates learning
Develops patient teaching guides and other materials to support patients and their social supports

Lead interdisciplinary groups to implement innovative patient care programs that address patient needs across the full continuum of care.

Review medication in collaboration with the physician and pharmacist for therapeutic effectiveness, appropriate to patient needs and in accordance with evidence-based practice and practice protocols

Work with patients in order to support compliance with and adherence to prescribed treatments

Provide information and advice on prescribed or over-the-counter medication on medication regimens, side-effects and interactions

Prioritize health problems and intervene appropriately to assist the patient in complex, urgent or emergency situations, including initiation of effective emergency care

Supports patients with the implementation of the health care plan including intervention and diagnostic testing

Acts as nursing leader for clinical teams
Plans, coordinates, and facilitates meetings for nursing team to improve access to quality care
Coordinates nursing and allied health student placements for the teams
In collaboration with the manager, participates in performance reviews for nursing and health care assistants
In collaboration with management, leads and participates in daily huddles for the team
Role-model, consult, and educate nursing staff to improve nursing practice and thus improve patient outcomes.

Working with the management, ensure the nursing team has access to and undertakes mandatory and statutory training requirements (i.e. Point of Care testing)

Act as a clinical leader in the delivery of nursing services, ensuring that the needs of the patient are a priority
Provide leadership in the development of evidenced-based policies, procedures and protocols, and best practice models/guidelines.

Work collaboratively with the health care team in the development, implementation and monitoring of chronic disease management programs around key health issues such as cardiovascular disease, diabetes, mental health and geriatrics.
Develop population profiles and conduct clinical inquiries to determine the need to change practice.
Actively seeks out emerging research and literature in the field, and interprets, communicates and disseminates research and academic literature findings to support quality patient care and recommend practice change
Collaborates on the development of program metrics to improve client, organization and system outcomes.
Reviews data for program evaluation and makes recommendations for quality improvement. Takes a leadership role in the implementation and evaluation of quality improvement projects
Takes a lead in the development, analysis and maintenance of policies and procedures, clinical guidelines, and innovative patient care supports in collaboration with internal and external stakeholders

Promote a proactive role in system redesign to support safety for patients and staff.

Enlist support and influence stakeholders and decision-makers in order to bring about new developments in the provision of services

Contributes to nursing and health care system by disseminating evidence based primary care health knowledge and practice through formal and informal channels, including presentations and publications
Enhances relationships among existing stakeholders and develops new partnerships
Engages community members in program development ensuring integration in various decision making and problem solving strategies.

As a role model and champion you will work to identify and integrate safe, best practices into daily activities to foster the delivery of safe and exemplary care.

The responsibilities described above are representative and are not to be construed as all-inclusive.

Qualifications/Skills :
Registered Nurse with the College of Nurses of Ontario in good standing
Master’s Degree in Nursing required; additional relevant certifications an asset
Current Basic Life Support certification
Minimum of five (5) years’ experience practicing primary care nursing
Specialized knowledge of one of geriatrics, mental health, cardiac, diabetes a strong asset
Experience providing telephone nursing practice
Recent leadership experience coupled with a high degree of professionalism and proven ability to work independently and within a multidisciplinary team
Understanding of adult education strategies, teaching and learning principles, and advanced therapeutic communication techniques
Ability to develop collaborative working relationships with a wide variety of internal and external stakeholders
Excellent computer skills, specifically with Electronic Medical Records and the Microsoft Office Suite
Must have excellent organizational, assessment, communication, counseling, and teaching skills
Strong analytical abilities with knowledge and skill in critical thinking and decision-making
Experience in research methodologies with demonstrated commitment to and continuing participation in research
Proficient in the utilization of information technology and data management

Experience working in an inter-professional team in a hospital setting preferred.
Works effectively as a strong team player and able to work independently
Ability to demonstrate empathy while remaining professional and respectful
Demonstrated commitment to continuing education, professional growth and maintenance of clinical competency is required

  • Professional behavior and communication that meets the standards of the professional regulatory college or association, as applicable, and the standards of Women’s College Hospital.
This position plays a critical role in acting as an advocate for safety and will demonstrate principles, practices and processes that will optimize a safe environment for all.

Women’s College Hospital is a fully affiliated teaching hospital of the University of Toronto and is committed to fairness and equity in employment and our recruitment and selection practices. We encourage applications from Aboriginal peoples, people with disabilities, members of sexual minority groups, members of racialized groups, women and any others who may contribute to the further diversification of our Hospital community. Accommodation will be provided in all parts of the hiring process as required under our Access for People with Disabilities policy. Applicants need to make their requirements known in advance.