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Care Transition Nurse
3 months ago
Company Overview
Home and Community Care Support Services South East is one of 14 organizations in Ontario dedicated to providing essential health care services, including home and community care, as well as long-term care home placement.
Previously recognized as Local Health Integration Networks (LHINs), these organizations now focus on delivering local health care while adapting to changes aimed at enhancing the health care system, ensuring that patients receive better-connected care through coordinated efforts among health care providers within Ontario Health Teams.
The service area spans from Brighton in the west to Prescott and Cardinal in the east, extending north to Perth and Smiths Falls, and back to Bancroft. These boundaries are for funding and planning purposes only, allowing residents to access health care services at their discretion, regardless of location.
Position Overview
CARE FOR OTHERS AND YOURSELF – THIS IS YOUR COMMUNITY
Are you a seasoned registered nurse with recent experience in acute or clinical settings, looking for a fulfilling career that prioritizes patient care while also supporting your professional development? You have found the right opportunity.
As a Transition Support Nurse, your primary responsibility will be to facilitate smooth transitions from acute care settings to home care for designated populations identified as complex, high-risk, or those with frequent emergency department visits. You will collaborate closely with Rapid Response Nurses, Regional Palliative Care Leads, and Service Provider Organizations (SPOs) to assist patients in need, with support from primary care providers, pharmacists, and community support agencies.
Whether your work takes place in our office, within the community, or in a healthcare facility, you will play a pivotal role in delivering connected, accessible, and patient-centered care, supported by a collaborative team of over 8,000 regulated health care professionals.
As a valued member of our team, your mission will be to enhance the health of our patients at home while benefiting from our commitment to your professional growth, personal wellness, and work-life balance.
Key Responsibilities
- Plan, organize, and deliver timely and effective care. Confirm hospital discharge plans and coordinate with hospital staff and Care Coordinators as necessary.
- Conduct nursing assessments in patients' homes and provide health education to patients and/or their families regarding illness management and prevention of acute episodes.
- Review discharge care plans and ensure that any outstanding medical tests are scheduled, coordinating support from family and friends as needed.
- Complete a Best Possible Medication History (BPMH) and provide medication management and education to patients and/or caregivers. Collaborate with pharmacists to ensure new prescriptions are filled and perform medication reconciliation to avoid drug interactions.
- Maintain communication with primary care providers, updating them on patients' acute care events and post-discharge plans.
- Recommend and facilitate follow-up visits as appropriate.
- Identify patients requiring expedited Care Coordination home assessments for home care services and work with Care Coordinators to arrange these visits.
- Assist Care Coordinators in developing clients' care plans and ensure a seamless transition to the ongoing care team.
- Provide health education and information to patients/caregivers, ensuring they have the necessary contact information for Home and Community Care Support Services South East.
- Deliver direct nursing care with non-complex skills for short stays or until discharge or transition to another care provider.
- Assess and promote a safe environment for clients, caregivers, family members, and staff.
- Participate in quality, risk, and patient safety initiatives.
- Assist in orienting new staff/students and fulfill preceptor responsibilities.
Qualifications
- A minimum of five (5) years of relevant experience as a Registered Nurse, with recent clinical/acute experience preferred.
- Current unrestricted registration as a Registered Nurse with the College of Nurses of Ontario.
- A University Degree in Nursing is preferred.
- Knowledge of community resources and the roles of multidisciplinary health care professionals.
- Understanding of the nursing process, consultation processes, program planning, and crisis management.
- Experience in emergency/critical care and community nursing is an asset.
- Completion of a critical care course in a relevant specialty is advantageous.
- Knowledge and ability to care for patients requiring IV therapy, Vascular Access Device management, palliative care, and wound management are assets.
- Current CPR-Level C & AED certification is required.
- A vehicle and valid Ontario driver's license are necessary.
- Proficiency in a Windows environment is expected.
- Compliance with a mandatory COVID-19 vaccination policy is required as a condition of employment.
Preferred Attributes
- Familiarity with direct care/case management models used in community health care.
- Understanding of health care legislation and practices.
- Significant knowledge of relationships with Home and Community Care Support Services South East, South East LTCHs, hospitals, community support services, and contracted providers.
- Practical knowledge of relevant legislation (e.g., Long-Term Care Act).
- Ability to communicate effectively, both verbally and in writing, across various settings.
- Proficiency in French or another second language is a plus.
What We Offer
We recognize that wellness is supported by work-life balance. In an inclusive culture that fosters continuous learning, growth, and innovation, we provide:
- Comprehensive compensation packages and benefits.
- Valuable professional development opportunities.
- Membership in a distinguished defined benefit pension plan.
About Us
We are Home and Community Care Support Services, dedicated to serving every individual in Ontario. We collaborate with patients and caregivers, primary care providers, hospitals, long-term care and retirement homes, service providers, and Ontario Health Teams to deliver responsive, accessible, integrated, and patient-centered care.
Our Commitment
We are committed to fostering a culture of equity, inclusion, diversity, and anti-racism. We strive to attract, engage, and develop a workforce that reflects the diverse communities we serve. We welcome applications from all qualified candidates and provide accommodations for individuals with disabilities during the recruitment process upon request.
We appreciate the interest of all applicants; however, only those selected for an interview will be contacted.
COVID-19 Vaccination Policy
Home and Community Care Support Services has implemented a mandatory vaccination policy across the province requiring all staff to be fully vaccinated against COVID-19. Candidates under consideration for employment will need to provide proof of vaccination documentation confidentially to Human Resources before their start date. Any requests for medical or human rights exemptions will be reviewed and validated prior to an employment offer.
