Transitional Leadership: The Transitional Lead works in collaboration with the client, family, substitute decision maker and community care providers to facilitate a holistic approach to care for persons presenting as high risk for responsive behaviours on transition to a long term care facility. The Transitional Lead will conduct a full assessment of the LTC eligible client, test recommendations and care strategies prior to transition and consult with other current community care providers including attending physician in order to create a Transitional Care Plan for implementation prior to and on arrival to the long term care facility.
DUTIES AND RESPONSIBILITIES
On receipt of a referral for a client that may present/ is presenting with moderate to high risk indicators for responsive behaviours that may lead to a high risk transition into a long term care facility will:
1. Conduct an in home assessment(s) on the individual in consultation with their family, formal and informal care givers, significant others as well as other service providers
2. Implement potential strategies and or recommendations for care, service, further assessment and or supports that may be required to deescalate the present situation and or prevent further escalation of the clients responsive behaviours in the home
3. Assesses the meaning, etiology and inherent risk of behaviours using an objective, systematic and holistic process that takes into account the physical, intellectual, emotional, and functional capabilities of the person, as well as the environmental and social aspects of their surroundings (PIECES)
4. Identifies and communicates with community support service agencies, family Physician, care support persons, specialists, religious affiliations ect to obtain additional effective and ongoing supportive care strategies to support the individual’s care
5. Focuses on prevention of responsive behaviours by relating well, manipulating the social and physical environment, focuses on persons’ abilities and knowing the individual and their life story and aspirations.
6. Identify the factors that may trigger/ precipitate responsive behaviours and accounts for these in care planning both in the home and at the receiving facility
7. Completes appropriate assessment tools independently and /by collecting data from other partners and services
8. Establish a Transitional Care Plan to share with current and potential providers to support the transition of the high risk individual to a Long Term Care Facility.
9. Continues to support the client and their family in their home in preparation for transition to a Long Term Care Facility through scheduled visits and implementation of strategies.
10. Facilitates care reviews/ complex case resolution meetings with potential LTCH’s who have this individual on their waiting list
11. Pre admission - reviews TCP with receiving home within 72 hours preceding admission
12. Supports the transition of the client to the LTCH on the day of admission; providing “report” and sharing assessments with the care staff and assisting the client and their family by implementing, coaching and modelling care strategies to the home staff
13. Consults with the BSO Mobile Manager for that home where extra PSW support may be required to assist in the transition of the client for specific scheduled care strategies and for further coaching and modelling of care strategies to the home staff as well as to trial new/additional care strategies to support the resident.
14. Provides consultation and/ direction to the BSO LTC Mobile staff. Evaluates BSO LTC Mobile staff members’ performance and provides feedback to the BSO Mobile Manager related to this case.
15. Makes recommendations for continued support or consultation for the holistic supportive care of the resident to the LTCH
16. Follows the client’s transition to the LTCH up to attending the 6 week post admission conference with supportive visits, coaching, modelling and mentoring home and LTC BSO Mobile staff.
17. Documents visits and recommendations on the homes electronic record as per agreed protocols
On referral from a LTCH where a previous client has had an escalation in risk behaviours that cannot be managed/ mitigated by LTCH following the HNHB Responsive Behaviour Protocol will:
18. Conducts an updated assessment(s) on the individual in consultation with their family, formal and informal care givers, significant others and other service providers to identify what has changed/ precipitated the change in the residents condition, potential medical/ physical/ pharmacological/ mental health factors that may be contributing to the present situation, care interventions trialed and the effectiveness of those interventions
19. Organizes and facilitates a care huddle/ complex case resolution meeting with the LTCH and the internal/ external supports (SGS, PRC, BSO, NLOT, Pain Consultant, attending physician ect) or other care resources available to the home
20. Documents visits, findings and recommendations in the homes electronic record.
Management and Supervisory Duties
19. Participates in interview and selection process of BSO Care Support workers, Clinical Coaches, and Behavioural Leads
20. Responsible for disciplinary action for BSO staff for offenses related to BSO Care pathways and assigned care treatment plans.
21. Directs care provided by CSWs and Behaviour Leads . Follows up on treatment and transition instructions provided and communicates feedback to staff. Assigns schedule changes to meet needs of high risk clients.
22. Develops policies and tools related to high risk BSO admissions. Trains and directs staff for such.
23. Supervises and maintains all required BSO program documentation and per established BSO pathways. Evaluates staff performance and completion of these assigned duties.
24. .Provide feedback for performance appraisals for CSW, Clinical coach, and Behaviour Lead.
25. Trains and demonstrates BSO role for high risk transitions to new Managers and Behavioural Leads.
26. Ensures that staff work in a safe and healthy manner in regards to high risk individuals, and that staff have received the necessary briefing and training to work with high risk individuals.
27. Provides feedback for contract proposals and development of the new TL role.
· * Demonstrated skill including superior assessment skills, including screening for depression, psychosis, suicide risk, cognitive status, ability in the use of appropriate assessment tools, and excellent skills in formulating comprehensive assessments in mental health, treatment and non pharmacologic therapeutic interventions
· Develops and maintains an effective working relationship with each LTCH, CCAC and external stakeholders
· Conducts regular speaking engagements and education in-services in member homes in their assigned regional hub regarding their role in transitional support.
· Develops and Implements regular quality improvement activities, implementation and evaluation of such.
· Develops and maintains effective referral and follow up system in collaboration with existing community resources and oversight committee.
· Assesses and prioritizes referrals based on client needs, potential date of LTCH admission and care requirements to ensure relationship building can be well established in advance of the LTCH admission
· Ensures regular and consistent communication through committee involvement and regular reporting as assigned by Director of Program and Services.
· Implements program changes as directed by the HBHNLHIN and authorized by the Director of Program and Services.
· Supervises and maintains all required BSO program documentation as per established BSO pathways.
· Maintains relationships and ongoing training and awareness with mental health program and supports within the community.
· Attends BSO meetings routinely as assigned
· Other duties as assigned by the Director of Community Programs and Services
HEALTH AND SAFETY RESPONSIBILITIES
· In addition to the above responsibilities, responsible for all the duties and responsibilities outline in the Occupational Health and Safety Act (R.S.O.1990 c.0.1).Ensures all staff follow proper protocol within the LTC community in regards to outbreaks, vaccine protocol, and quarantines
KNOWLEDGE, SKILL AND EXPERIENCE
Demonstrates knowledge of dementia, delirium, mental health issues in the delivery of care and its effect on the person and family members or partners in care enhanced by extensive previous experience working with this population.
Extensive knowledge of Disease processes, stages and progression, diagnostic and assessment process, cognitive or neurological symptoms, treatment interventions (non-pharmacological) and strategies to promote optimal quality of life.
Excellent communication and interpersonal skills, consultative and facilitation experience working with families, care givers, care partners, health care providers and the public.
Extensive knowledge of the health care and community service partners serving the BSO population across the continuum of care, including how to liaise with them and how to transfer information
Confidence and capacity to deliver person-centered care which recognizes both the uniqueness of each person and an awareness of one’s own contribution to that relationship, including personal attitudes, values and actions, knowledge, competence and confidence in utilizing adult learning principals
(a) FORMAL EDUCATION
A University degree and current registration in a related regulated health care profession
Minimum 3 years demonstrated expertise in working with older adults with mental health illness
Extensive knowledge, skills and experience in the assessment/care planning for older adults and the use of clinical assessment tools as they relate to complex physical health problems including pain, chronic disease management, delirium, metabolic disorders, cognitive function and impairment including dementia as well as other neurological disorders (additional familiarity with ABI and developmental disabilities co-occurring with a dementia is preferable), mental health care problems including mood disorders, anxiety, psychotic disorders with a variety of underlying causes, longstanding mental health illness including personality disorders, schizophrenia.
(b) OTHER KNOWLEDGE, SKILL AND EXPERIENCE
Familiarity with Quality Improvement, program development, evaluation and research methodology would be an asset.
A minimum of 3 years health care experience working with complex older adults
Demonstrated well developed knowledge of psychiatric and geriatric disorders.
An ability to draw upon his/her own knowledge and experiences to confidently respond to clinical questions/situations in-the-moment as they arise in community, LTC and/or conference setting
Excellent coaching skills and the ability to facilitate the development of these skills in others
Expertise in acting as a team member, leader, mentor, educator, preceptor and maintain partnership networks
Superior communication skills (verbal, written and interpersonal) and ability to adjust language or terminology to meet the needs of the audience.
Demonstrated ability to manage workload, determine priorities and meet deadlines and adapt to and the ability to work in unpredictable stressful situations.
Demonstrated ability to work independently and to function as an effective member within an interdisciplinary tea
Extensive working knowledge of community resources for Geriatrics/Mental Health.
Proficiency in the use of computing software such as Word, PowerPoint, Point Click Care, Clinical Connect and Microsoft Access.
Driver’s license and the ability to travel across the Niagara Region
Job Type: Full-time
Salary: $38.00 /hour