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Patient Transition Nurse
3 months ago
Company Overview
Home and Community Care Support Services South East is one of the 14 organizations dedicated to providing essential health care services in Ontario, focusing on home and community care as well as long-term care home placements.
Previously known as Local Health Integration Networks (LHINs), these organizations have transitioned to their current roles under Ontario Health, ensuring that local health care services continue to be delivered effectively during the ongoing improvements to the health care system.
Our commitment is to provide patients with seamless, connected care, working collaboratively with health care providers as part of Ontario Health Teams.
The South East region encompasses a diverse area, allowing residents to access health care services of their choice, regardless of geographical boundaries.
Role Overview
CARE FOR OTHERS – YOUR WORK MATTERS
We are seeking a skilled registered nurse with recent clinical experience who is passionate about providing care in a supportive environment. As a Transition Support Nurse, your primary responsibility will be to facilitate smooth transitions from acute care settings to home care for patients identified as complex or high-risk.
You will collaborate closely with Rapid Response Nurses, Regional Palliative Care Leads, and Service Provider Organizations (SPOs) to ensure that patients receive the necessary support, with additional backing from primary care providers, pharmacists, and community support agencies.
In this role, whether in an office, community, or healthcare facility, you will take the lead in delivering accessible, patient-centered care, backed by a team of over 8,000 regulated health care professionals.
Your mission will be to promote the health and well-being of our patients at home while benefiting from our commitment to your professional development, personal wellness, and work-life balance.
Key Responsibilities
- Organize and deliver timely, effective care while confirming hospital discharge plans and coordinating with hospital staff and Care Coordinators.
- Conduct comprehensive nursing assessments in patients' homes and provide education on illness management and prevention of acute episodes.
- Review discharge care plans, ensuring all necessary medical tests are scheduled and family support is coordinated.
- Complete a Best Possible Medication History (BPMH) and provide medication management and education in collaboration with pharmacists.
- Maintain communication with primary care providers to update them on patients' acute care events and post-discharge plans.
- Facilitate follow-up visits as needed.
- Identify patients requiring expedited home assessments for care services and collaborate with Care Coordinators.
- Assist in developing care plans and ensure smooth transitions to ongoing care teams.
- Provide essential health information to patients and caregivers, ensuring they have the necessary contact information.
- Deliver direct nursing care for non-complex cases until discharge or transition to another provider.
- Promote a safe environment for clients, caregivers, and staff.
- Engage in quality assurance and patient safety practices.
- Support the orientation of new staff and students, fulfilling preceptor duties.
Qualifications
- A minimum of five (5) years of relevant nursing experience, with a preference for recent clinical experience.
- Current unrestricted registration as a Registered Nurse with the College of Nurses of Ontario.
- A University Degree in Nursing is preferred.
- Familiarity with community resources and the roles of multidisciplinary health care professionals.
- Understanding of the nursing process, consultation, program planning, and crisis management.
- Experience in emergency/critical care and community nursing is advantageous.
- Completion of a critical care course in a relevant specialty is a plus.
- Knowledge and experience in caring for patients requiring IV therapy, pain management, and wound care are beneficial.
- Current CPR-Level C & AED certification is required.
- A valid Ontario driver's license and access to a vehicle are necessary.
- Proficiency in a Windows environment is expected.
- Compliance with the mandatory COVID-19 vaccination policy is required.
Preferred Skills
- Understanding of direct care and case management models in community health.
- Knowledge of health care legislation and practices.
- Strong relationships with Home and Community Care Support Services South East and local health providers.
- Practical knowledge of relevant legislation, such as the Long-Term Care Act.
- Effective verbal and written communication skills in various settings.
- Ability to communicate in French or another second language is an asset.
What We Offer
We recognize the importance of work-life balance and wellness. Our inclusive culture supports your continuous learning and professional growth, offering:
- Comprehensive compensation packages and benefits.
- Opportunities for valuable professional development.
- Membership in a defined benefit pension plan.
Our Commitment
Home and Community Care Support Services is dedicated to serving all individuals in Ontario. We collaborate with patients, caregivers, primary care providers, hospitals, long-term care facilities, and community service providers to deliver integrated, patient-centered care.
Equity and Inclusion
We are committed to fostering a culture of equity, inclusion, diversity, and anti-racism. We encourage applications from all qualified individuals and provide accommodations for persons with disabilities during the recruitment process upon request.
We appreciate all applicants for their interest; however, only those selected for an interview will be contacted.
Vaccination Policy
Home and Community Care Support Services has implemented a mandatory vaccination policy requiring all staff to be fully vaccinated against COVID-19. Applicants under consideration will need to provide proof of vaccination prior to their start date, with any exemption requests reviewed accordingly.
