Primary Nurse, Hospital to Home Program

Wednesday, January 22, 2025

Job Description

The Primary Nurse, Client Services, Hospital to Home Program is responsible for monitoring patient progress from admission to transition by ongoing assessment of needs, progress, and care plan. They work collaboratively with patients, families, Personal Support Workers (PSWs), and allied health professionals (OT, PT, SW) to achieve program goals and reduce preventable hospital readmission. The Primary Nurse will provide education, support, and monitoring of PSWs as well as communicate effectively to ensure staff are aware of changes in the client’s status in a timely manner. The Primary Nurse enhances coping of patients and families with therapeutic communication, information, and education to support a positive patient experience. The Primary Nurse works closely with the Service Coordinator and Program Supervisor to ensure patients receive quality care and service as required for their patient care pathway. In addition, the Primary Nurse has an important role in monitoring for adverse outcomes, communicating with primary care providers, and ensuring any changes in care are implemented immediately.

We are looking for: a full-time permanent Primary Nurse
Salary: Commensurate with experience
Hours of Work: 34 hours/week. This role is primarily based in the community with some requirements to be in the office. There is an on-call requirement which includes at least one week every three weeks from 4:30pm to 8:30am including weekends.
Reports to: Manager, Community Programs

Responsibilities

Nursing

• Establish a trusting and respectful relationship 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.
• 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 and liaise with the hospital care team as needed to identify barriers to care and collaborate with patients to overcome these challenges, ensuring they receive the appropriate support for their well-being when a patient is discharged for the duration of the program.
• Deliver supportive health education, including 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.
• Work closely with community partners, such as Ontario Health at Home, to ensure the effective transition of patients after the program ends.
• Promote needs-based, ethical practices, and health equity in recommending professional services and social prescribing for patients.

Conduct In-Home Client Assessments

• Ongoing assessment/reassessment of patients’ needs for service according to program and organizational guidelines and develop care plans based upon patient health and functioning level; support network; and home environment.
• Complete medication reconciliation on admission and discharge.
• Complete InterRAI-HC tool for each patient on admission.
• Complete all necessary documentation and obtain the required consent.
• Advocate on behalf of the patient to ensure their needs are met.
• Complete initial and follow-up client goal achievement, with patient/caregiver input.
• Participate in case conferences and huddles.
• Maintain regular contact with Manager and Service Coordinators.

Monitoring/Training Personal Support Workers

• Provide PSWs with patient risk factors to support safe care.
• Communicate effectively to ensure all PSWs and others as needed are aware of changing patient needs and information.
• Monitor PSW care when assessing patients.
• Provide training and follow-up on Delegated Acts.
• Provide direction to PSWs during crisis situations/urgent visits such as medical emergencies.
• Follow all rules/procedures regarding the 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.

Contribute to 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.

Qualifications

• Must be a Registered Nurse with current registration with CNO.
• Prior experience working as part of an integrated team with knowledge of regulated and unregulated health care providers.
• Experience working in the home care sector or hospital sector with an elderly population or in community-based care is considered an asset.
• Competency in Inter-RAI tools or willing to learn.
• Excellent knowledge of the social determinants of health, impact on clinical outcomes.
• Knowledge of safe moving and handling and other environmental home safety hazards in people’s homes.
• Experience in patient assessments involving personal support to ensure quality outcomes.
• Experience in teaching PSWs related to assigned tasks (Special Functions) such as oral medication, safe moving and handling, mechanical lift training review, skin health, emptying urinary catheter drainage systems, emptying ostomy appliances.
• 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.
• Computer skills in Windows and Word processing.
• Language skills are an asset (e.g. Russian, Yiddish, Cantonese, Italian).
• Valid Driver’s license and vehicle required.

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.

Powered by people. Sparked by passion. Circle of Care is made up of staff, students, and volunteers who bring energy and purpose, every day.

• 4211 Yonge St, North York, ON M2P 2A9, Canada