Primary Care Networks (PCN) consists of Family Doctors and Nurse Practitioners (NPs), in partnership with Alberta Health Services, to coordinate health services for patients. The Bow Valley PCN encompasses 8 clinics, 46 physicians/ 2 NP members. A number of health care professionals work closely with physicians and NPs to support patient care.
As a member of the PCN’s Interdisciplinary Health Team, the Registered Nurse (RN) works in partnership with the medical home team to ensure delivery of high-quality evidence-based health care to the practice population. The RN is responsible for care across the continuum of health needs within a number of defined family practice settings in an interprofessional environment. The RN will provide assessment, education and lifestyle counselling for patients with, or at risk for, a wide range of chronic and/or complex health conditions commonly encountered in the Primary Care setting, with a strong focus on mental health. Other, episodic duties within the scope of practice of an RN may be required (i.e. assistance with clinical procedures, injections, etc.). This position involves provision of patient and family care, group facilitation and education, consultation and collaboration with health care teams, and other referral and community groups. This role includes seeing patients for a variety of reasons including mood and anxiety concerns, occupational problems, relationship difficulties, sleep disturbances, bereavement, chronic pain, addiction concerns, and/or adjustment disorder, and chronic disease management.
The PCN Registered Nurse (RN) is responsible for:
➢ Assessment, Intervention, Education and Advocacy
• Assists individuals and their families/support network, achieve their optimal physical, emotional, mental, spiritual health and well-being.
• Acts as a health coach to provide support, advice and additional resources to empower patients to achieve goals in health behaviour change and ultimately self-management.
• Coordinates services, including referral, and care with the medical home team and others involved in the circle of care to ensure the patient’s needs are met in a timely manner.
• Under limited supervision, works collaboratively with medical home team scheduling appointments, arranging for follow-ups of clients to other services.
• Provides a broad scope of nursing services based on highly developed knowledge and skills.
• Makes professionally autonomous decisions in managing patient care.
• Supports a comprehensive, proactive service delivery model within participating clinics, to ensure patients are assessed and screened according to current best practice guidelines.
• In partnership with the medical home team, develops and implements individual health plans with a focus on functional outcomes, health education, promotion of effective coping
strategies, and utilization of resources
• Regularly monitors, evaluates, and adjusts the health plan based on effectiveness of interventions and/or changes in condition or environment, in collaboration with the patient
and medical home team.
• Identifies problems rapidly, uses appropriate assessment approaches and tools to direct treatment, clinical consultation, case management, education and referral services for patients.
• Provides ongoing system coordination and navigation which may include connecting patients with Alberta Health Services and additional community services.
• Communicates relevant patient information to appropriate physicians and caregivers while ensuring communication of confidential information only to authorized persons.
• Applies principles of population-based care, and will provide brief, solution focused, and goal directed approach with patients.
• Identifies educational requirements and readiness of patient as a component of an overall health assessment.
• Assists family physician with assessment, recognition and treatment of mental health disorders and psychosocial problems.
• Works with the medical home team to treat and manage care for patients with chronic emotional and/or health problems efficiently and effectively.
• Detects at risk patients and develops plans to prevent further psychological or physical deterioration.
• Assists in preventing relapse or morbidity in conditions that tend to recur over time.
• Employs health promotion and education strategies to support behaviour changes conducive to positive mental health (e.g. smoking cessation, weight management,
substance use and adherence to recommended lifestyle changes).
• Acquires and maintains a comprehensive understanding of community services and referral processes, including diagnostic services, specialists, hospital care, rehabilitation and support
programs, educational programs.
• Applies established guidelines for primary care, chronic/complex disease, addictions and mental health.
• May be required to recommend titration of medications according to physician order, specialist recommendations and/or treatment algorithms.
• Works in a flexible, responsive manner to provide nursing services in a variety of practice environments within the medical home.
• Participates in clinical working groups as required.
• Works collaboratively within the PCN to enhance the delivery of primary care services.
Team Responsibilities
• Supports the implementation of strategies for improving the quality and provision of care for the practice population.
• Works together to achieve collaborative care with members of the medical home and PCN.
• Promotes programs and services that support patient care.
• Ensures the maintenance of up to date and accurate records in the Electronic Medical Record (EMR) to optimize patient care and adhere to the practice policy.
• Participates in data collection and evaluation as required.
• Offers training support for team members and assist in their professional development.
• Initiates and maintains positive community partnerships.
• Acquires and maintains expertise in the management of chronic/complex mental health conditions and mental health treatment modalities (e.g. behavioural health, solution
focused) consistent with relevant guidelines and best practices.
• May be required to facilitate group education or classes.
Applicants must have the following qualifications & experience:
• Current unrestricted registration with CARNA
• Bachelor’s Degree in Nursing
• 5 or more years of clinical experience, preferably in a primary care setting
• Current CPR
• Experience working in primary care with patients experiencing mental health and/or chronic conditions
• Addictions and/or behavior change training or experience is an asset
• Experience in rural health preferred
• Experience with Electronic Medical Records (EMRs)
• Ability to flex time as required (evenings and weekends)
• Valid driver’s license and own vehicle as travel is required
Other Job-Related Requirements:
• Proficient in basic computer skills (Microsoft 365 Suite, email, EMR)
• Vulnerable sectors criminal record check
• Proof of immunizations in compliance with PCN policies
__________________________________________________________________
A full time (1.0 FTE) position is 38.75 hours/week. Salary is commensurate with qualifications and experience. Extended health benefits, RRSP matching and vacation allotment are part of the total compensation following successful completion of a 3-month probationary period.
At the Bow Valley Primary Care Network, we value diversity and how it enriches our workplace and community. Our aim is to foster a safe and equitable workplace that reflects the diverse Bow Valley community, where all team members belong; inclusive of gender, sexuality, skin colour, disability, where you come from, or any other identifying factors and how these intersect.
The Bow Valley PCN is an equal opportunity employer, and we are actively committed to providing an inclusive, supportive and respectful workplace for all employees. Our hiring practices ensure that all qualified candidates are considered, and decisions are merit-based. We invite qualified applicants with diverse skills, experiences, and backgrounds to apply. Applications (CV and Cover letter) can be forwarded to: mlittle@bowvalleypcn.ca. If you are not an existing Bow Valley resident, please provide information regarding your plans for relocation in the Bow Valley in your cover letter. This position is open until successfully filled. We thank all those who apply, however only those selected for an interview will be contacted. If you require reasonable accommodation in completing this application, interview, or to participate in any part of the recruitment process, please direct your inquiries to mlittle@bowvalleypcn.ca.