Job Summary

The Family Practice Nurse will work in close collaboration with physicians and other interdisciplinary health professionals including Nurses, Nurse Practitioners, Social Workers, Dietitian and Pharmacist.  As a vital member of the team, the Registered Nurse is responsible for delivering quality nursing care to patients with a focus on assessment, health education, disease prevention, as well as the early identification and support for chronic health conditions.

Education:

• Certificate of Competence  and current membership with the College of Nurses of Ontario (CNO)
• BScN preferred
• Current CPR or basic Cardiac Life Support (BCLS) registration

Experience:

•  Minimum of 3-5 years experience providing patient care to patients of all ages in a comprehensive Family Practice or relevant Ambulatory care setting.
• 3-5 years experience providing patient care across the spectrum of problems encountered in Family Medicine/Primary Care
• Demonstrated achievement of good working relationships with colleagues, professional staff and the interprofessional team
• Previous experience with an electronic medical record (EMR) program or willingness to learn electronic record keeping using a clinical management system (CMS)
• Highly developed ability to organize time and set priorities effectively
• Ability to work independently with minimal supervision
• Ability to make clinical decisions within professional domain

Qualifications:

•  Demonstrated leadership and strong interpersonal skills
• Effective verbal and written communication skills
• Excellent decision making, problem recognition, problem solving skills, negotiation and conflict resolution skills
• Ability to work in an inter-professional team environment and implement best practices in patient care
• Ability to prioritize, manage time effectively and be flexible in a very active work environment

 Roles and Responsibilities:

 This is not intended as an all-inclusive list, but rather a sample of the duties and responsibilities required of the position.  Duties and responsibilities may vary over time.

Direct Care:

• Systematically assess patients’ physical and psychosocial needs
• Assist patients and their families in identifying resources to maximize the patient’s health
• Perform direct clinical care to patients including procedures such as: immunizations, throat swabs, TB skin test, suture removal, wound dressing, ear syringing, blood pressure monitoring, etc.
• Assist other team members with clinical procedures, etc.
• Perform telephone patient triage and monitoring within the clinic setting as required
• Provide appropriate and accurate telephone assessment advice and follow-up (eg. Discuss test results, test preparations, medications, etc) as necessary
• Provide health education, health promotion, counseling to patients and their families across the continuum of care including immunization, chronic disease management, well baby and family care
• Report and record accurately and appropriately, using electronic charting

Coordination:

• Initiate appropriate action in response to changing patient needs and collaborate with the interprofessional team to assist patients
• Arrange appropriate follow-up, referrals, appointments and investigations according to established procedures.
• Collaborate on the design and delivery of chronic disease prevention and management programs.  Assist in monitoring and evaluating the success in achieving CDM program objectives.
• Assist in coordinating programs and arranging follow-up care

Administration:

• Collect accurate and comprehensive patient-related information and document this information in the electronic clinic management system.
• Prepare monthly/quarterly reports for the Ministry of Health and Long Term Care (MOHLTC)
• Willingness to routinely participate in staff meetings

Education/Advocacy:

• Help patients to identify and use health resources
• Support team health care programs including Diabetes, Smoking Cessation, COPD, etc. and deliver health education programs for patients
• Participate in the educational process of other health team members and students of all disciplines
• Participate in the orientation of new staff members and students
• Actively seeks out formal and informal opportunities to enhance knowledge and expertise.

 

Teamwork:

• Work with the team to develop collaborative approaches to family practice for the management of clinical problems in primary care
• Establish, promote and maintain good relations with patients and staff
• Support and maintain the goals and objectives of the West Durham Family Health Team
• Communicate effectively with patients, team members and external agencies involved in the patient circle of care

 If you enjoy working in a team and collaborative environment providing patient care and health promotion education, please e-mail your resume and cover letter by November 30, 2016 to:

 Andrea Petroff, Executive Director, West Durham Family Health Team

 apetroff@westdurhamfht.com .

 Thank you in advance for your interest.  Please note that only candidates selected for interviews will be contacted.

 

 

 

 

This document explains how to use standardized queries in your EMR to start building chronic disease registries. The instructions below focus on Depression. Depression affects about 5 percent of the Canadian population aged 15 years and over during any given year, and affects 12% of Canadians at some point in their lifetime [Statistics Canada’s 2012 CCHS]. The Conference Board of Canada said in a report released in September 2016 that depression costs the Canadian economy at least $32.3 billion annually in lost productivity. Despite the magnitude, burden of illness, and social and economic costs associated with depression, there continues to be societal stigma and self-stigma that discourage individuals and families from seeking treatment and support. While there are real barriers, FHTs can provide access to different treatment options through their interprofessional teams. In order for a FHT program to be efficient and effective, the right patients need to be enrolled. Normally programs require the doctor to remember to enroll the appropriate patient into a program. However, that process for a handful of patients will be slow and least effective. Instead, FHTs can use a Depression Search tool, developed by the AFHTO Algorithm Project team, to identify the patients in their FHT that have depression. Our depression search tool has been developed using the CPCSSN case definition and the input from subject-matter experts at Hamilton FHT and St Michaels’ Hospital. The tool has been tested, revised, and validated using the eHealth Centre of Excellence EMR environment. The depression search tool is comprehensive, does not require any data cleaning prior to use, and is plug-and-play. At final testing, the tool achieved 96% sensitivity and 62% positive predictive value (PPV); in simple terms, this means that if the search tool identifies 100 patients, 62 patients will actually have depression. This is a starting point for a manual validation of a depression registry. Query criteria (click to see larger view)            

The Depression query is intended for teams that do not yet have a reliable list of patients with depression and don’t have the time or resources to start from scratch in reviewing all their patients to generate such a list.  Right now, it is also only for teams with PSS or Accuro although work is continuing to expand the standardized query to OSCAR and Nightingale. The following steps will help your team use the query to generate a list of CHF patients, starting from your EMR.  

Step 1. Estimate how many patients you think this will affect.  Multiply the number of patients your team serves by 0.05 (the average rate of depression in Ontario) to get a rough idea of how many of your patients likely have depression.  If you still think this is a big enough group of patients for you to generate a registry for, carry on to step 2.

Step 2. Import the query into your EMR.  Right now, you can only do this if you have either Telus PSS or QHR Technologies Accuro EMRs.  You will likely need the help of your QIDSS, IT staff or other person who usually works with your EMR to do this.

• For PSS, import the PSS SRX file into your EMR. Contact improve@afhto.ca for the file.
• For Accuro, download the query “AFHTO Depression Frontend Search”from their publisher.

We are in the process of creating similar queries for OSCAR. Contact improve@afhto.ca for more information.

Step 3.  Run the query in your EMR.  Again, you might need the help of your QIDSS, IT staff or other person who usually runs queries in your EMR. Running the query will produce a list of patients with depression. The list will not be perfect – probably 38% of the patients identified by the query will NOT have depression. The query gets you STARTED in building the depression registry but doesn’t do the whole job for you.

Step 4. Find the patients who might not have depression. Review the list of patients generated by the query to separate out those patients that are clearly already coded as having depression. What’s left will the list of patients who MIGHT have depression based on other data in the EMR besides formal coding.

Step 5. Prepare your physicians to review the list  Subdivide the list of possible patients with depression into separate, shorter lists for each physician. Work with your physicians to find out if they would prefer a list on paper or electronically and how they might like it sorted (i.e. by name or most recent visit or some other parameter).

Step 6.  Invite each physician to review their list of patients.  They know their patients best and can likely quickly confirm which ones do or do not have depression, even though that information might not be easy for others to find in the EMR.

Step 7.  Clean up your EMR data.  Add depression codes to the EMR for each patient that the physician confirms as having depression. This so-called “data cleaning” work is a great job for a student.  AFHTO has created a toolkit to assist members in recruiting and using students for data clean-up. Click here for the toolkit.

Step 8.  Re-run the query. After you have corrected the EMR, re-run the query to generate a list of patients with depression. This is your new depression patient registry. Going forward, you can run the query anytime you need to generate a list of patients with depression.  You can use the list to invite patients to a depression program, track progress with outcomes on these patients or any other purpose.   Once identified, you can recruit patients to your depression program and improve patient prognosis, management, and overall care. Here are some example outcome measures to apply for this program:

• % of patients who show an improvement in PHQ-9 score
• % of patients who show improvement on CES-D
• % of patients hospitalized
• % of patients with action plans
• % of patients self-identifying as satisfied after a group session

See this space for more on resources and contacts in supporting teams set up care programs for depression. This query was produced by and for QIDSS with assistance from eHealth Centre of Excellence in support of all AFHTO members.  If you have any questions, please contact improve@afhto.ca.