VHA Home HealthCare (VHA) is one of the largest not-for-profit home care providers in Ontario. Our team is made up of close to 3,000 caring and committed professionals who love what they do. Our providers tell us: “Home care is where I can truly make a difference. There is such a sense of accomplishment from helping people live independently at home.” Our teams work together to provide high quality, client-centred care to those who need it most in their homes, schools, retirement homes and other community settings. Many of our team members manage their own schedules in the community and they say, “The freedom and flexibility can’t be beat.” Providers form meaningful bonds with the clients and families they serve over time and are supported by a diverse regional team and beneficial home office programs. Team members tell us “I love the inclusive culture. I feel welcome and at home.” View more comments from our clients and their family members. Pay Range Base Salary: $61,000 - $76,000 (commensurate with experience) If you're a Registered Nurse (RN), this opportunity is for you! The Home Care Specialist will provide care coordination, case management, and system navigation services to clients enrolled in the Hospital@Home, Hospital to Home and OHT-lead programs/projects and other integrated care programs. This role plays a key part in supporting clients through their transition from hospital to home and continues to provide case management throughout their participation in the program. Acting as a liaison between home care clients, hospital partners, primary care and community care teams, the Home Care Specialist ensures continuity of care and alignment with program objectives. The position also fosters strong collaboration with program funders to enable smooth, client-centered transitions, while contributing to quality improvement efforts aimed at optimizing patient flow, care coordination, and service delivery within the programs. #LI-MD1 #INVHACorp Key Areas of Accountability: Coordinates services within the clients home, community, delivery and pick up of medical equipment and supplies as needed based on program-specific workflows Conduct occasional hospital visits to support hospital discharge planning or participate in case conferences for complex cases Conducts home visits with the client following program-specific timelines to complete comprehensive assessments in partnership with the program funder, client and family to inform the development client goals within the program and an individualized client care plan Arranges and adjusts home care services according to the care plan and in alignment with services contained within the program bundle Monitors appropriate service allocation and bundle management Attends program huddles with internal teams, hospital partners and/or program funders Arranges appointments and liaise with the client’s primary care provider within set program specific timelines, supports the client to connect with primary care when required Completes documentation after encounters with clients and their care team and communicates any risk-related events to the VHA team in a timely manner Completes referrals to appropriate community services when needed and facilitates a seamless and supporting transition to these services Provides direct care to the client and trains staff on delegated acts as required Monitors program metrics and participates in program evaluation and process improvement Key skills, experience and behaviours required for this position: Undergraduate degree in Nursing (RN Required) 5+ years of experience in home and community health or a related field Member, in good standing with College of Nurses of Ontario Knowledge of the health care delivery system including hospital discharge planning, home and community care, and support services Excellent skills in case management, coordinating care within interdisciplinary teams, interRAI assessments and navigation of community services Excellent assessment and decision-making skills Passion for excellent customer service and customer experience Effective time management skills, with the ability to work independently and co-operatively in a busy multidisciplinary environment in various settings (e.g. at the hospital, in the office, in the community). Proficient skills in Microsoft Office (Word, Excel, PPT) and comfort with learning/working with new and emerging technologies (e.g. EHR systems, reporting systems) Intersectoral experience and excellent relationship building skills and dispute resolution Must be available for on-call support A valid driver’s license and access to a reliable vehicle What makes VHA’s compensation unique? Benefits and pension plan for permanent eligible employees Compensation for education and professional development VHA is a leading learning organization so we can provide you with comprehensive orientation and training at the start and throughout your career Mentorship and peer support Career development opportunities Employee and family assistance program Wellness resources Perks & discounts Staff & service provider events Accommodation and VHA’s commitment to DEI At VHA Home HealthCare (VHA), we passionately strive to uphold our commitments to being an Equal Opportunity Employer. We champion inclusion and diversity in all parts of our organization and are strong believers that a diverse workforce is key to the ongoing and future success of VHA. We aim to review all applicants with fair and unbiased recruitment practices where opportunities are presented based on merits, skills, and experience. VHA is committed to providing reasonable accommodation and our services are accessible and sensitive to the needs of diverse groups. If you require any accommodation, please let us know in advance as we are happy to comply. How to Apply? Our online application should take about 5 to 10 minutes to complete. VHA is accredited with Exemplary Standing by Accreditation Canada; an RNAO Best Practice Spotlight Organization designate; and a founding member agency of United Way Greater Toronto. Thank you to everyone who applies. We will review applications as they are received. We’ll only be contacting those selected for further discussion. In every role and at every level, we lead with purpose, build bonds that matter, and we’re passionate about providing spectacular care. “VHA’s team is full of amazing people who are compassionate and committed to supporting one another and to making care better for our clients and families.” - Kathryn Nichol, President and CEO, VHA Home HealthCare (VHA) At VHA, we offer you opportunities to advance your career with an industry-recognized leader in care that truly values its clients and its people. Visit our Careers website for more details. Internationally educated healthcare professionals have long been an important part of VHA’s workforce - hear from some of our staff and service providers about their experience. Since 1925, VHA Home HealthCare has lent a helping hand to people in the community. As a not-for-profit charitable organization, we support seniors, families, people with disabilities and those living with chronic or terminal illness to live as independently as possible. With close to 3,000 staff and service providers - including personal support workers, nurses, rehabilitation professionals, home support workers and office support staff - we provide services 24 hours a day, seven days a week to clients in their home and the community. At VHA, we’re passionate about the work we do, the impact we make, and about supporting our clients, communities, and each other. As a VHA team member you’ll do more than provide services to clients; you’ll build strong, long-lasting bonds and real relationships with our clients and their families. We offer high-quality, multilingual services in southern Ontario and our work environment focuses on supporting clients and staff through client-centered care, well-connected health care teams, and continual improvement. Our people are as diverse as the clients and communities we support and we value your unique talents. So, if you’re passionate about serving others and making a difference, you belong at VHA A Life-Changing Opportunity Providing better care to our clients and their families is what fuels us. And today we’re at the forefront. Through our community partnerships, innovation initiatives, and a focus on research and transformation, we are making an impact like never before. To support you and your goals, there are a range of full-time, part-time and casual positions at VHA with varying schedules to meet our clients’ needs and your own. We also try to give you an interesting mix of new and repeat clients so you can build relationships and enjoy variety. We know that our team members can provide their best care when their own needs are being met. Together, we are reimagining the future of health care. Reimagine your career with VHA. At VHA, we offer you opportunities to advance your career with an industry-recognized leader in care that truly values its clients and its people. We offer: The opportunity to join a leading charitable organization you can be proud of with over 95 years of experience providing high quality care. A stimulating, diverse, client and family-focused work environment with a variety of full-time and part time positions. We invest in our staff, offering continuous opportunities for learning, competitive compensation and paid orientation, a confidential and free Employee Assistance Program, and more. Eligible staff are also entitled to a pension plan and comprehensive benefits package. Best of all, we foster a supportive, and respectful team environment where we all thrive.