Full Time Registered Nurse - Rapid Response Transitional Team

CARE AND BE CARED FOR – THIS IS YOUR HOME

Are you an experienced registered nurse seeking a rewarding career that cares for others, in a professional practice that cares for you? You’re looking in the right place.

If so, take a look at this rewarding career opportunity working alongside a supportive and collaborative team of over 8,000 regulated health care and other professionals. We are amid a momentous time for health care in Ontario as we move to a more connected health care system through the Ontario Health Teams model of care.

As a Rapid Response Registered Nurse, you will ensure effective transitions from acute to home care and prevent existing patients from going to the hospital for the following target population frail adults with complex needs and/or high risk characteristics. You will also ensure communication and linkage with primary care provider and provide timely and effective rapid response home care.The Rapid Response Registered Nurse (RN) provides the first in-home nursing visit within 24 hours from hospital discharge for high needs seniors and adults. During this visit, the RN will confirm the patient hospital discharge care plan, complete a nursing physical assessment, and communicate the importance of connection to primary care to avoid re-hospitalization.

What do we offer?

We know wellness is supported with work-life balance. In an inclusive culture committed to support your passion for continuous learning, growth and innovation, we offer

• Attractive comprehensive compensation packages
• Valuable development opportunities
• Membership in a world class defined benefit pension plan.

What will you do?

• Leads and/or participates in and demonstrates an understanding of quality, risk and patient safety principles and practices
• The RN will collaborate with other members of the interdisciplinary team including care coordinators, nurse practitioners, pharmacists and contracted service providers.
• Refer the patient to Health Care Connect if the patient has no primary care provider
• Provide health teaching and information to the patient/caregiver and ensure they have the hCCSS contact information
• Identify patients requiring an accelerated assessment and home care services and coordinate with the care coordinator and/or nurse practitioner to facilitate the assessment
• Perform other duties as assigned
• Works within the basic principles of patient safety by doing the right thing for the right patient, using the right method at the right time.
• Adheres to the HCCSS' patient safety policies and procedures.
• Review the discharge care plan and confirm that outstanding investigations have been scheduled and transportation is available. Liaise with hospital staff and care coordinator in regards to discharge plan
• Ensure contact with primary care provider and provide an update on the patients acute care event and post discharge regime. Recommend and facilitate a follow up visit as appropriate and/or within 7 days after discharge from the hospital.
• Directly or in partnership with a pharmacist, ensure new prescriptions are filled and conduct a medication review and reconciliation. Review the medication protocol with the patients and/or caregiver and provide health teaching
• Follows all safe work practices and procedures and immediately communicates any activity or action which may constitute a risk to quality, and patient safety
• Collaborate with the care coordinator to develop the patient’s care plan and ensure a smooth transfer of the primary care provider and pharmacist to the ongoing care team
• Link patients with service providers
• Complete a nursing physical assessment in the patient’s home and provide health teaching to the patient and/or family regarding their illness/symptom management and avoidance of re-occurrence of acute episode
• Participate in establishing; maintaining and monitoring standards for the HCCSS direct nursing providers, including committee work and active participation and contribution to quality initiatives
• Promotes patient safety in alignment with the Vision, Mission, Values and Strategic Directions of the HCCSS
• Act as a spokesperson as required and interpret the role of the HNHB HCCSS to patients, healthcare professionals and to the public. Ensure positive public relations and effective coordination of services through ongoing liaison and participation in internal and external committees. Assess for and promote a safe environment for patients, caregivers, family members and staff. Adhere to health and safety policies and practices developed and implemented by the HCCSS

What you must have?

• Advanced education in gerontology and/or chronic disease management
• Registered Nurse

What would give you the edge?

• Knowledge of direct care/case management models used in community health care organizations
• Working knowledge of community resources and roles of health care professionals
• Solid knowledge of health care related legislation and practices
• Knowledge of HCCSS priorities, policies, practices and service standards
• Minimum of 5 years of relevant experience as a registered nurse. Experience in Internal Medicine, ED, Cardiac, Geriatric medicine in acute care or community setting
• Recent clinical/acute experience within 2 years.

Who are we?

We are Home and Community Care Support Services, ready to serve every person in Ontario. We partner with patients and caregivers, family physicians, hospitals, long-term care and retirement homes, service providers and Ontario Health Teams, to deliver responsive, accessible, integrated, patient-centred care.

Why join us?

If you’re interested in driving excellence in care and service delivery, and seeking an unparalleled opportunity to lead and learn, partner and connect, care and be cared for, this is your home.

Equity, Inclusion, Diversity and Anti-Racism Commitment

Home and Community Care Support Services is committed to a culture of equity, inclusion, diversity and anti-racism. We are committed to attracting, engaging and developing a workforce that reflects the diverse communities we serve. We welcome and encourage applications from all qualified applicants. Accommodations for persons with disabilities required during the recruitment process are available upon request