Transition Support Nurse

at  Home and Community Care Support Services South East

COMPANY BIO

Home and Community Care Support Services South East is one of 14 Home and Community Care Support Services organizations in Ontario with a focused mandate to deliver local health care services such as home and community care and long-term care home placement.
These organizations were previously known as Local Health Integration Networks (or “LHINs") at a time when they also led local health care planning and funding, and those functions are now part of Ontario Health.
Home and Community Care Support Services South East is dedicated to ensuring the ongoing delivery of local services while Ontario makes changes to improve the health care system to give patients better-connected care with health care providers working as one coordinated team in Ontario Health Teams.
The south east region extends from Brighton on the west, to Prescott and Cardinal on the east, north to Perth and Smiths Falls, and back to Bancroft. The boundaries are for funding and planning purposes only. Residents of the Home and Community Care Support Services South East can seek health care services wherever they prefer, inside or outside these boundaries.

CARE AND BE CARED FOR – THIS IS YOUR HOME

Are you an experienced registered nurse, with recent acute or clinical experience, seeking a rewarding career that cares for others, in a professional practice that cares for you? You’re looking in the right place.
As a Transition Support Nurse, you will be responsible for ensuring effective transitions from acute care to home care for target populations defined as complex, high risk and/or populations with high emergency department utilization. You will work directly with Rapid Response Nurses, Regional Palliative Care Leads and Service Provider Organizations (SPOs) to support patients in need, supported by primary care, pharmacists and community support agencies
Whether you work in our office, in the community, or a health care facility – you will play a lead role in providing connected, accessible, patient-centred care – and be supported by our collaborative team that includes over 8,000 regulated health care and other professionals.
As a valued team member, your mission will be to help our patients be healthier at home, while you benefit from our supports for professional growth, personal wellness and work-life balance.

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 and benefits
• Valuable development opportunities
• Membership in a world class defined benefit pension pla

• Plan, organize and provide timely and effective care. Confirm hospital discharge plan and liaise with hospital staff and Care Coordinator in regards to patient discharge if required
• 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.
• Review the discharge care plan and confirm outstanding medical tests are scheduled, coordinating family/friends supports as needed.
• Complete a Best Possible Medication History (BPMH) and provide teaching and medication management as required with the patient and/or caregiver. In partnership with a pharmacist, the TSN ensures new prescriptions are filled and facilitates a medication reconciliation to confirm no drug interactions or contraindications
• Ensure contact with primary care provider, providing an update on the patient’s acute care event and post discharge regime.
• Recommend and facilitate a follow up visit as appropriate
• Identify patient’s requiring an accelerated Care Coordination home assessment for home care services and work with the Care Coordinator to facilitate the home assessment visit.
• Inform and support the Care Coordinator in developing the client’s care plan and ensuring a smooth transfer of the primary care physician and pharmacist to the ongoing care team.
• Provide health teaching and information to the patient/caregiver and ensure they have Home and Community Care Support Services South East contact information
• Direct nursing care with non-complex skills for a short stay or until discharge or transition to another Direct Care Provider.
• Assess for and promote a safe environment for clients, caregivers, family members, and staff.
• Participates in and demonstrates an understanding of quality, risk and patient safety principles and practices
• Assists with the orientation of new staff/students and carries out preceptor responsibilities

What must you have?

• Minimum of five (5) years of relevant experience as a Registered Nurse, with recent clinical/acute experience preferred
• Holds current appropriate unrestricted registration as a Registered Nurse with the College of Nurses of Ontario
• University Degree in Nursing preferred
• Working knowledge of community resources and roles of multi-disciplinary health care professionals
• Working knowledge of the nursing process, the consultation process, program planning and crisis management
• Emergency/critical care and community nursing experience an asset
• Completion of critical care course in area of specialty an asset
• Demonstrate knowledge, experience and ability to care for patients with the following would be an asset: Initiation and maintenance of IV therapy, Intermate/CADD pump, Vascular Access Device management, Palliative pain and symptom management, wound management skills
• Hold current CPR- Level C & AED certification
• Vehicle and valid Ontario driver’s license is required
• Proficient in a Windows environment
• We have a mandatory COVID-19 vaccination policy. As a condition of employment, all employees are required to submit proof of COVID-19 vaccination status prior to start date.

What would give you the edge?

• Knowledge of direct care / case management models used in community health care organizations.
• Knowledge of health care related legislation and practices
• Significant understanding of relationship with Home and Community Care Support Services South East and South East LTCHs, hospitals, community support service and contracted service providers.
• Practical knowledge of relevant legislation (e.g. Long-Term Care Act)
• Ability to deliver information effectively, verbally and in writing, in a variety of settings
• Ability to speak French or another second language

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 and benefits
• Valuable development opportunities
• Membership in a world class defined benefit pension plan

Who are we?
We are Home and Community Care Support Services, ready to serve every person in Ontario. We partner with patients and caregivers, primary care providers, 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.