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2 months ago
Position Overview
Registered Nurse - Transition from Hospital to Home
Are you a dedicated registered nurse, physiotherapist, occupational therapist, social worker (MSW), dietitian, or speech-language pathologist looking for a fulfilling career that prioritizes the well-being of others while also valuing your professional growth? You have found the right opportunity.
Key Responsibilities
- Conduct thorough geriatric behavioral assessments utilizing the PIECES framework alongside additional geriatric evaluations.
- Collaborate with care team members, including patients and caregivers, to formulate a detailed behavioral care plan tailored to address primary behaviors during transitional phases. This team may include hospital personnel, LHIN representatives, discharge planners, physicians, and various resource consultants.
- Perform a Best Possible Medication History and communicate findings with the care team. Engage with pharmacy professionals to facilitate medication adjustments and ensure adherence to medication management protocols.
- Work in conjunction with the LHIN Case Manager to connect with primary care physicians, geriatricians, or geri-psychiatric specialists, providing updates on patient conditions following hospital discharge. Recommend and arrange follow-up appointments as necessary.
- Address inquiries and concerns from clients and caregivers, supporting the implementation of the behavioral management care plan.
- Provide assessment, consultation, and treatment as required.
- Employ an ABOE (Assessment, Behavior, Outcomes, and Evaluation) approach, sharing observations with the care team and caregivers.
- Document assessments and care plans in the LHIN CHRIS database, OSLER, and the HEADWATERS Hospital MEDITECH database.
- Contribute to data entry for tracking program metrics.
- Serve as a representative when necessary, clarifying the role of the LHIN to clients and healthcare professionals, ensuring effective public relations and service coordination through active participation in committees.
- Assist in the orientation of new staff and students, providing refresher training for existing staff as needed.
- Evaluate and promote a safe environment for clients, caregivers, family members, and staff, adhering to health and safety policies established by the LHIN and associated hospitals.
- Engage in maintaining and monitoring Best Practice standards for the geriatric behavioral population, contributing to committee work and quality initiatives.
Required Qualifications
- Ability to support staff and family members in a person-centered approach to develop and implement behavioral care strategies while monitoring patient responses over time.
- Commitment to the mission and values of the LHIN.
- Knowledge of community resources and the roles of healthcare professionals.
- Comprehensive understanding of healthcare legislation and practices.
- Familiarity with direct care and case management models in community health organizations.
- Awareness of LHIN priorities, policies, practices, and service standards.
- Registered Nurse (BScN or diploma) in good standing.
- Completion of a Case Management Certificate is advantageous.
- Experience with the relevant training and models.
- Gentle Persuasive Approach (GPA) training is essential.
- Proven experience meeting documentation standards set by the College of Nurses of Ontario.
- Crisis Prevention Intervention Training is beneficial.
- CNA certification in Geriatrics is preferred.
- Current CPR certification.
- Minimum of two years of relevant experience as a Registered Nurse focused on care coordination for adults in mental health or specialized geriatrics, particularly in dementia care.
- Specialized skills in assessing delirium, dementia, and mental health, with knowledge of best practices in these areas.
- Ongoing annual recertification in BCLS/BLS or CPR at the Healthcare Provider level.
Preferred Qualifications
- Experience working with diverse patient populations, including multicultural, homeless, palliative, acquired brain injury (ABI), mental health, geriatrics, and pediatrics.
- Background in case management or recent related community experience.
- Proficiency in French or another second language is a plus.
What We Offer
We understand that wellness is enhanced by work-life balance. In a culture that values continuous learning, growth, and innovation, we provide:
- Competitive compensation packages and benefits.
- Valuable opportunities for professional development.
- Membership in a prestigious 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, caregivers, family physicians, hospitals, long-term care facilities, service providers, and Ontario Health Teams to deliver responsive, accessible, integrated, and patient-centered care.
Why Choose Us?
If you are passionate about enhancing care and service delivery, and seek an exceptional opportunity to lead, learn, connect, and provide care, this is the right environment for you.
Commitment to Equity, Inclusion, Diversity, and Anti-Racism
Home and Community Care Support Services is devoted to fostering a culture of equity, inclusion, diversity, and anti-racism. We strive to attract, engage, and develop a workforce that mirrors 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.
