Registered Nurse- Chronic Disease Management (CDM)

Reporting to the Program Manager or designate, the Registered Nurse (RN) supports the delivery of primary care services in the family practice or primary care network clinic setting. The RN uses the nursing process as a member of, and in collaboration with, the multidisciplinary team in the delivery of consistent quality care to meet the needs of the patient/client.

The RN accepts responsibility for continuing competency and full scope of practice in the primary care setting through ongoing professional development, adherence to practice standards, and participation in quality improvement activities. The RN provides restricted activities and care within the full scope of practice as defined by the College of Registered Nurses of Alberta (CRNA) Standards of Practice and Competencies, and adheres to the Code of Ethics for RNs, Edmonton O-day’min Primary Care Network (EOPCN) policies and procedures, and primary care partner clinics’ policies and procedures.

Practice Setting: The RN practices in a primary care clinic setting with physicians and other healthcare professionals as a member of a multidisciplinary care team and works with patients (and their identified care partners) suffering from or at risk of chronic conditions such as diabetes, hypertension, asthma, COPD, cancer, and arthritis.

The position is currently located at the EOPCN Central Office and is subject to change depending on organizational needs.

KEY RESPONSIBILITIES & DUTIES

• Collects, documents and reports health information from objective and subjective sources to identify patient/client health needs, in accordance with legal, ethical, organizational, and professional requirements.
• Utilizes relevant and evidence-based, credible resources and tools in care planning and intervention.
• Collaborate with patients, physicians, and multidisciplinary teams in developing patient-centered care plans to address client needs and preferences, establishing clear goals agreed upon by the client and health care team.
• Maintains therapeutic nurse-client relationships and ensures privacy and confidentiality of health information.
• Supports and contributes to safe, healthy, and positive practice environments by following occupational health and safety practices, infection control and other safety measures to protect self, patients, and colleagues from illness/injury.
• Utilizes knowledge of primary health principles and social determinants of health utilized in care planning and health promotion.
• Practices in a culturally competent manner and serves as a client advocate.
• Has knowledge of evidence-based, standardized assessment tools and pathways relevant to CDM.
• Performs clinical procedures which may include but are not limited to vital signs, 24hr blood pressure monitoring, spirometry, cervical screening (PAP), minor wound care, and injections.
• Provides patient counselling and health teaching, addressing topics such as healthy lifestyle, risk reduction behaviors and preventative self-care.
• Facilitates goal setting using SMART goals and health change methodology concepts.
• Facilitates patient education using various teaching techniques adapted to the patient learner using health literacy principles.
• Performs case management, screening, coordination, and follows lab results.
• Observes, reports to the appropriate person, and documents deviations and changes in client status in response to interventions.

QUALIFICATIONS:

• Bachelor of Nursing or Bachelor of Science in Nursing Degree through an accredited university
• Current and active registration with CRNA and CPR C for Healthcare Provider
• Knowledge of chronic diseases such as diabetes, hypertension, obesity, COPD/asthma, heart failure, hypertension including pathophysiology, clinical practice guidelines, treatment, and resources for same
• Knowledge of models of client care, with emphasis on interdisciplinary collaboration and patient/family-centered care and working knowledge of local and provincial primary health resources
• Experience using electronic medical records and proficiency with Office 365 Suite
• A minimum of one year of primary care nursing experience is preferred
• Certified diabetes educator is preferred
• Tobacco educator certification is an asset.
• Case management training/certification, Health Change Methodology certification, Health Literacy Training, and Nonviolent Crisis Intervention training is an asset
• Ability to communicate effectively orally, electronically or in writing
• Physically capable of performing duties related to position (i.e., assisting clients with physical disability such as assisting to a chair, some lifting a variety of clinic equipment or teaching materials). Willingness to learn new skills.
• A Criminal Record/Police Information Check with Vulnerable Sector check