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About the Role
The Visiting Nurse, Hospital to Home Program optimizes patient progress from admission to transition, providing nursing interventions, health teaching, and transition support. This role involves ongoing assessment, collaborative work with patients, families, and allied health professionals to reduce preventable hospital readmissions, and educating/monitoring Personal Support Workers (PSWs). The Visiting Nurse enhances patient and family coping through therapeutic communication and education, ensuring quality care and service delivery in alignment with patient care pathways. They also monitor for adverse outcomes and ensure timely implementation of care changes.
Responsibilities
- Establish trust and respect with patients/family to understand their goals and preferences for care.
- Facilitate a smooth transition from hospital to home by providing supportive, non-judgmental care and guidance.
- Review the Patient Service Plan, plus the Referral Information Package for critical patient details.
- Conduct comprehensive assessments of patient needs and connect them with primary care providers and relevant services.
- Accept patient referrals, clarify questions with the Manager, and liaise with hospital care team.
- Collaborate with patients to overcome transition challenges, ensuring they receive appropriate support.
- Deliver supportive health education, including chronic disease self-management strategies.
- Maintain accurate, timely, and thorough professional documentation of patient interactions, care plans, and progress.
- Initiate transition planning throughout service and work closely with community partners for warm handoffs.
- Promote needs-based, ethical practices, and health equity in recommending professional services and social prescribing.
- Review the supply inventory available in the patient’s home and report any gaps or needs.
- Conduct in-person community visits at patients’ homes.
- Provide ongoing assessment/reassessment of patients’ needs according to program guidelines.
- Develop care plans based upon patient involvement to optimize their health and functional status.
- Complete medication reconciliation on admission and discharge.
- Complete InterRAI-HC tool for each patient prior to their discharge from the program.
- Ensure all necessary documentation is completed and required consents are obtained.
- Return all healthcare records to the office following the patient’s discharge.
- Submit Professional Service Reports within three days of the initial visit.
- Submit Transition/Discharge Reports as requested or within 7 days of discharge.
- Perform treatment-based interventions as required, including IV therapy, wound care, catheterization, and medication administration.
- Advocate on behalf of the patient to ensure their needs are met.
- Complete initial and follow-up goal achievement, with patient/caregiver input.
- Participate in case conferences and huddles.
- Maintain regular contact with Manager and Service Coordinators.
- Use motivational interviewing with patients and families and engage patients and families in partnership using empathy.
- Provide after-hours support to patients and their families as needed.
- Carry out delegation or shadow visits for Personal Support Workers.
- Ensure PSWs are informed of patient risk factors to support safe care.
- Communicate effectively to ensure the team is aware of changing patient needs and information.
- Monitor impact of PSW care when visiting patients.
- Provide training and follow-up on Special Functions such as oral medication, safe moving and handling, mechanical lift training review, skin health, emptying urinary catheter drainage systems, emptying ostomy appliances.
- Provide direction to PSWs during crisis situations/urgent visits.
- Follow all policies/procedures regarding the role of PSWs, health and safety of patients and PSWs.
- Monitor for patient falls risks and promote safe moving and handling.
- Participate in H2H huddles and transition meetings at regular intervals.
- Support program requirements and timelines.
- Work collaboratively with external stakeholders, hospital partners, and internal team.
- Participate in the weekend rotation as per the Master Schedule.
- Receive a Transfer of Accountability Report via email or phone message from the patient’s Primary Nurse before initiating nursing care during weekend shifts.
- Conduct teaching visits for PSWs or shadow visits that cannot be completed during business hours.
- Prioritize patients admitted to the program who require nursing visits during the first seven days of admission.
- Identifying and reporting health and safety incidents and concerns in a timely manner.
- Participating in health and safety processes and procedures.
- Participating in maintaining a safe workplace environment.
- Participating in all health and safety training initiatives.
- Taking proactive action against patient incidents within scope of practice.
- Developing a plan to identify, manage and/or minimize patient safety risks.
- Assessing the severity of an adverse patient safety/risk event and determining the best follow-up.
- Evaluating potential hazards and identifying patients at risk, taking preventative measures.
- Reporting all safety events impacting patients, caregivers and families.
Requirements
- Registered Nurse or Registered Practical Nurse with current registration with CNO.
- Experience working as part of an integrated team with knowledge of regulated and unregulated health care providers.
- Experience working in home or hospital with elderly population or in community-based care.
- Commitment to evidence-informed clinical practice, outcome measures, professional practice models, and CNO practice requirements in Ontario.
- Commitment to person-centered care and cultural diversity.
- Knowledge of population health and vulnerable populations (elder adults, Indigenous people, people living with mental health and addictions, LGBTQ+).
- Excellent knowledge of the social determinants of health, impact on clinical outcomes.
- Knowledge of safe moving, handling, and other environmental home safety hazards.
- Experience in patient assessments involving personal support to ensure quality outcomes.
- Knowledge of home safety equipment used in home care and funding/ordering procedures.
- Knowledge of medical supplies used in home care for wound care and other needs.
- Commitment to evidence informed clinical practice and outcome measures, professional practice models and professional college practice requirements in Ontario.
- Excellent oral/written communication and collaboration skills.
- Ability to work in a fast-paced setting with excellent problem-solving and assessment skills.
- Excellent interpersonal, problem-solving, and communication skills.
- Highly organized, able to work independently.
- Competency in Inter-RAI tools and Microsoft Office.
- Must have a valid Drivers License and access to a vehicle.
- French language proficiency is an asset.
- Flexibility in schedule, required to be on-call for additional program support as needed.
Skills
- Nursing interventions
- Health teaching
- Transition support
- Patient assessment
- Therapeutic communication
- Collaboration
- Medication administration
- IV therapy
- Wound care
- Catheterization
- Documentation
- InterRAI tools
- Microsoft Office
- Motivational interviewing
- Problem-solving
- Assessment skills
- Interpersonal skills
- Organizational skills
- Independent work
Location
- Central Toronto
- West Toronto
Work Type
- Full-Time
- Contract
- Travel required
Experience Level
- 1 Year Contract
Education Level
- Registered Nurse or Registered Practical Nurse with current registration with CNO
Salary/Compensations
- $65,000 to $76,500 per year
About the Company
- Circle of Care is committed to fostering an inclusive, accessible environment, where all employees, volunteers and clients feel valued, respected and supported.
- We are dedicated to building a workforce that reflects the diversity of the communities in which we live and serve, and creating an environment where every employee has the opportunity to reach their potential.
- Circle of Care seeks applicants who embrace our values of equity, anti-racism, and inclusion.
- Powered by people. Sparked by passion. Circle of Care is made up of staff, students, and volunteers who bring energy and purpose, every day.
Equal Opportunity
- We encourage applications from candidates who have been historically disadvantaged and marginalized, including but not limited to those who identify as First Nations, Métis and/or Inuit/Inuk, Black, members of racialized communities, persons with disabilities, women and/or 2SLGBTQ+.
- We are committed to an environment that is barrier free. If you require accommodation, please inform us in advance.
- Circle of Care may use artificial intelligence (AI) through third-party platforms, to assist in parts of the recruitment and/or selection process.
- Only applicants who are selected for an interview will be contacted.