Job Description

The Visiting Nurse, Hospital to Home Program is responsible for optimizing patient progress from admission to transition, providing any required nursing interventions, health teaching, and transition support. The Visiting Nurse will provide ongoing assessment of needs, progress and care plan. They work collaboratively with patients, families, Personal Support Workers, and allied health professionals to achieve program goals and reduce preventable hospital readmission. The Visiting Nurse will educate, support and monitor PSWs as well as communicate effectively to ensure staff are aware of changes in client’s status in a timely manner. The Visiting Nurse enhances coping of patients and families with therapeutic communication, information, and education to support a positive patient experience. The Visiting Nurse works closely with the Service Coordinator and Manager to ensure patients receive quality care and service as required by their patient care pathway. In addition, the Visiting Nurse will monitor for adverse outcomes, communicate with primary care providers and ensure any changes in care are implemented immediately.

We are looking for: 2 full-time contract Visiting Nurses (1 Year)

Hours of Work: Vacancies require 8am to 4pm Monday to Friday availability or requires 12pm to 8pm Monday to Friday availability. Requirement to be part of a weekend rotation.

Reports to: Program Manager, Sinai Hospital to Home

Responsibilities

Nursing

• 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 throughout the process.
• Review the Patient Service Plan, plus the Referral Information Package for the reason for hospitalization, surgical procedures, past medical history, list of diagnoses, reportable signs and symptoms, medical orders for nursing, follow-up appointments, and list of discharge medication.
• Conduct comprehensive assessments of patient needs and connect them with primary care providers and relevant services such as PT, OT, PSS, SW, RD, SLP.
• Accept patient referrals from the hospital, clarify any questions with the Manager, and liaise with hospital care team as needed to identify barriers to care
• Collaborate with patients to overcome transition challenges, ensuring they receive the appropriate support for their well-being.
• Deliver supportive health education, including chronic disease self-management strategies, to patients dealing with complex or chronic health conditions.
• Maintain accurate, timely, and thorough professional documentation of patient interactions, care plans, and progress as per CNO standards and Circle of Care policies.
• Initiate transition planning throughout service and work closely with community partners, such as Ontario Health at Home for a warm handoff.
• Promote needs-based, ethical practices, and health equity in recommending professional services and social prescribing for patients.
• Review the supply inventory available in the patient’s home and report any gaps or needs to the Manager to ensure adequate supplies are available for ongoing treatment.

Conduct In-Home Client Assessments

• Complete in person community visits at patients’ home.
• Provide ongoing assessment/reassessment of patients’ and their need for service according to program and organizational 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 from the hospital, following the Records Management return process.
• Submit Professional Service Reports within three days of the initial visit and submit Transition/Discharge Reports as requested or within 7 days of discharge.
• Perform treatment-based interventions as required, including but not limited to: IV therapy, wound care, catheterization, and medication administration. All interventions must fall within the scope of nursing practice and be based on physician orders.
• 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 to manage frustration and escalation.
• Provide after-hours support to patients and their families as needed.

Monitor/Training Personal Support Workers

• 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 such as medical emergencies.
• Follow all policies/procedures regarding the role of PSWs, health and safety of patients and PSWs while providing care.
• Monitor for patient falls risks and promote safe moving and handling as per evidence informed standards.

Team effectiveness and service development

• 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.

Weekend Rotation

• Nurses are required to work weekends in rotation with Visiting Nurse team and complete a holiday rotation, depending on team size. During weekend/holiday shifts, nurses will be scheduled to see patients according to standard practice. Urgent visits will be incorporated into the weekend rotation to ensure timely patient care.
• Participate in the weekend rotation as per the Master Schedule.
• Nurses working on the Weekend Rotation will receive a Transfer of Accountability Report via email or phone message from the patient’s Primary Nurse before initiating nursing care.
• Weekend visits will be scheduled by the Service Coordinator and may include visits to provide treatment such as wound care, comprehensive assessment, catheter insertion, Medication Administration Oral/IV, based on patient needs.
• Conduct teaching visits for PSWs or shadow visits that cannot be completed during business hours to oversee PSWs working evening shifts.
• Prioritize patients admitted to the program, who are obligated to receive nursing visits during the first seven days of admission.

Risk, Health and Work Place Safety

• Identifying and reporting health and safety incidents and concerns in a timely manner as per policy.
• Participating in health and safety processes and procedures.
• Participating in maintaining a safe workplace environment by cultivating a positive safety culture and encouraging best practices to promote both staff and client safety and well-being.
• Participating in all health and safety training initiatives on a regular basis.
• Taking proactive action against patient incidents within scope of practice.
• Developing a plan to identify, manage and/or minimize patient safety risks or situations in adherence with risk management operations policies.
• Assessing the severity of an adverse patient safety/risk event and determining the best follow-up and developing an action plan following the event.
• Evaluating any potential hazards and identifying patients at risk for adverse health and safety events, taking preventative measures when necessary to minimize reoccurrence.
• Reporting all safety events impacting patients, caregivers and families in a timely and honest disclosure.

Qualifications

• 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.

Additional information

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. As such, 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.

We thank you for your interest in Circle of Care. We welcome you to apply for this role, even if you do not meet every requirement listed. Only applicants who are selected for an interview will be contacted.

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