Hospital 2 Home

**Together, we do amazing things every day.**

Imagine a supportive employer, a career that fits your lifestyle, and many learning opportunities. With the Hamilton Family Health Team, you can have all of that, and more. We work hard to create an innovative and diverse workplace that values the contributions of our employees. No matter what your role, working with us is about making a difference - every day

**Your Opportunity**

Established in 2014, the Hospital 2 Home (H2H) program provides specialized care for patients who are impacted by chronic conditions and face social or economic barriers to achieving good health.

This program is run through Hamilton Health Sciences (HHS) and aims to improve: patient outcomes and patient experience while ensuring the right care is provided in the right place at the right time by the right person/team.

The Hamilton Family Health Team (HFHT) is partnering with the H2H program by adding this RN position to the team to support the work of the team and develop a warm transition plan for existing patients of the HFHT and attaching patients to the HFHT where feasible. The role will be developed through the collaborations with the leadership of the H2H program and HFHT and evolve based on the needs of the patients and health care providers.

**Duties and Responsibilities**

• Accept referrals, triage patients, and liaise with the hospital care team to understand barriers and challenges when a patient is discharged.
• Build a trusting relationship to understand the patient’s goals.
• Facilitate a successful transition to home with a supportive, non-judgmental approach.
• Assessing patient's needs, supporting connection with other services such as Ontario Health at Home including Rapid Response Nursing (RRTT), Community Paramedicine, Pharmacy or other community services and supports.
• Assess barriers to care and support patients to overcome these challenges.
• Provide supportive health teaching including the development of self-management skills for patients with complex or chronic heath challenges.
• Maintain accurate documentation.
• Foster and maintain collaborative relationships with their MRP.
• Connect patients with primary care as needed to ensure ongoing care and follow up.
• Liaise with community partners (e.g. Ontario Health atHome, visiting nurses) as needed.
• Connect patients with primary care and groups that will support their ongoing well-being.
• Identify HFHT patients who may benefit from H2H involvement.

Patient experience

• Support patients and their caregivers, ensuring that their questions are answered, and a seamless care approach is in place.
• Share a confident approach to answer questions and have supportive conversations about their health conditions and social determinants of health.
• Ensure that patients are aware of community support and facilitate access to supports as required.

Quality and Performance Improvement

• Participate or lead CQI activities as needed (e.g. case debrief, critical incident review, etc.)
• Respond to patient/family concerns in a timely and sensitive manner
• Develop and deliver educational programs and presentations (i.e. to other healthcare providers, to the broader public etc.) to build relationships.
• Develop, track, and report quarterly outcome measures

**Education and Experience**

• Registered Nurse in good standing with the College of Nurses of Ontario with experience supporting patients with complex and chronic diseases and struggling with social determinants of health.
• Strong understanding of all healthcare services in the Hamilton area.
• Experience providing a caring approach to care and supporting both patients and their caregivers.
• Experience with outreach and supporting patients in their home environment or partnering with others to support patients to remove barriers through their care journey.
• Exceptional and compassionate interpersonal and communication skills to collaborate with patients, caregivers, other care providers.
• Strong knowledge of relevant legislation including but not limited to Freedom of information and Protection of Privacy Act, Regulated Health Provisions Act.

Location(s)

Office location may vary across HFHT hubs. Travel and home visits are a requirement of the role.

Resources

Hospital 2 Home: The Right Care at the Right Time (hamiltonhealth.ca)

Why join the HFHT?

Competitive Employee Value Proposition including, but not limited to

• Healthcare of Ontario Pension (HOOPP)
• Extended health care benefits including health, dental, vision & critical Illness insurance
• Meaningful, purpose-based work
• 12 paid Stat holidays and one (1) extra float day
• Flexible work schedule
• Ongoing green initiatives

**Application Instructions**

Interested applicants please submit résumé and cover letter as one document using naming convention

We thank all applicants for their interest, only those selected for an interview will be contacted.

**Note**

**Benefits**

• Casual