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Nurse for Transition Support Services
3 months ago
Company Overview
Home and Community Care Support Services South East is one of the 14 organizations dedicated to delivering local health care services across Ontario, focusing on home and community care as well as long-term care placements.
Previously recognized as Local Health Integration Networks (LHINs), these organizations now operate under Ontario Health, which has taken over local health care planning and funding responsibilities.
Our commitment is to ensure the seamless delivery of local services while adapting to changes aimed at enhancing the health care system, ultimately providing patients with better-connected care through coordinated efforts within Ontario Health Teams.
The geographical area we serve 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 primarily for funding and planning purposes, allowing residents to access health care services wherever they choose, regardless of these limits.
Position Overview
CARE AND BE CARED FOR – THIS IS YOUR HOME
Are you a seasoned registered nurse with recent experience in acute or clinical settings, looking for a fulfilling career that prioritizes the well-being of others while also valuing your professional growth? You are in the right place.
As a Transition Support Nurse, your role will involve facilitating effective transitions from acute care to home care for specific 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 environment is our office, the community, or a healthcare facility, you will take a leading role in delivering connected, accessible, and patient-centered care, backed 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 support for professional development, 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 all outstanding medical tests are scheduled, coordinating support from family and friends as needed.
- Complete a Best Possible Medication History (BPMH) and provide necessary teaching and medication management to patients and/or caregivers. Collaborate with pharmacists to ensure new prescriptions are filled and facilitate 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 arrange follow-up visits as appropriate.
- Identify patients needing expedited Care Coordination home assessments for home care services and work with Care Coordinators to facilitate these visits.
- Support Care Coordinators in developing clients' care plans and ensuring smooth transitions to the ongoing care team.
- Provide health education and resources to patients/caregivers, ensuring they have 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 the orientation of 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.
- 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 an asset.
- Completion of a critical care course in a relevant specialty is advantageous.
- Knowledge and experience in caring for patients requiring IV therapy, Vascular Access Device management, palliative care, and wound management would be beneficial.
- 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 our mandatory COVID-19 vaccination policy is required prior to the start date.
Preferred Attributes
- Understanding of direct care/case management models in community health care.
- Knowledge of health care legislation and practices.
- Significant understanding of relationships with Home and Community Care Support Services South East, long-term care homes, hospitals, and community support services.
- 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 an asset.
What We Offer
We recognize that wellness is supported by work-life balance. In a culture that values continuous learning, growth, and innovation, we provide:
- Attractive compensation packages and benefits.
- Valuable opportunities for professional development.
- Membership in a defined benefit pension plan.
Our Commitment
We are dedicated to serving every individual in Ontario. We collaborate with patients, caregivers, primary care providers, hospitals, long-term care facilities, service providers, and Ontario Health Teams to deliver responsive, accessible, integrated, and patient-centered care.
Equity, Inclusion, Diversity, and Anti-Racism Commitment
Home and Community Care Support Services is 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 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. Candidates being considered for employment will need to provide proof of vaccination documentation to Human Resources before their start date. Any requests for medical or human rights exemptions will be reviewed and validated prior to an offer of employment.
