At Home and Community Care Support Services Toronto Central by providing an accessible workplace, we want all of our employees to feel valued, appreciated, and free to be who they are at work. That is why we are intentionally committed to diversity and inclusion by providing an accessible and inclusive work place for all persons. We are strongly committed to include Black, Indigenous, visible minorities, Francophone, 2SLGBTQ+ persons, neurodiversity, women, national origin, ancestry, disability status, age, marital status, pregnancy, citizenship, all faiths, or any other aspect, which makes them unique, through recognizing each applicant through anti-racism and anti-oppressive practices to ensure equitable opportunity.
As an integral part of this specialized team of nurses, the Rapid Response Nurse (RRN) provides support for a safe transition from acute care to home care for medically complex older adults with cardiorespiratory symptoms and/or a confirmed diagnosis of COPD or CHF. The RRN communicates closely with the patient's primary care provider/physician, while providing timely and effective chronic disease management. The RRN provides an in-home nursing visit within 3 to 5 business days for patients referred to the program. During this visit, the nurse will confirm the patient hospital discharge care plan if indicated, communicate the importance of primary care to avoid re-hospitalization, and perform medication reconciliation for the patient. This chronic disease management program provided by RRNs is up to 15 weeks in length of stay and is a combination of in home visits and telephone follow-up. Currently, the RRNs are working Monday to Friday from 8:30am-4:30pm.
- Reviewing the discharge care plan and confirming outstanding medical tests have been scheduled and transportation etc. is available.
- Either directly or in partnership with a pharmacist, ensures new prescriptions are filled and conducts a medication reconciliation to confirm no drug interactions or contradictions. Review medication protocol with client and caregiver and answer any questions.
- Either directly or through the Care Coordinator, initiates contact with primary care physician and provides update on client acute care event and post-discharge regime. Recommends and facilitates, as appropriate, a one-week client follow-up visit with the primary care physician.
- Assessment, consultation, and treatment, as indicated; triage client priorities between new referrals and existing caseloads.
- Identifies clients requiring an accelerated assessment and home care services and works with the Care Coordinator to facilitate the home assessment visit.
- Works collaboratively with team members to provide timely triage of referred clients from the ED and in-patient units using standardized tools and processes
- Informs and supports the Care Coordinator in developing the client’s care plan and ensuring a smooth transfer of the primary care physician/provider and pharmacist to the ongoing care team.
- Registered Nurse in good standing with the College of Nurses of Ontario
- Minimum of five 3-5 years of relevant experience as a Registered Nurse
- Working knowledge of community resources and roles of 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
- CNA certification in an area of specialty: GNC (C) or CNCCP (C) an asset
- Solid knowledge of health care related legislation and practices
- Knowledge of direct care/case management models used in community health care organizations.
- Knowledge of Home and Community Care Support Services priorities, policies, practices and service standards
- Effective interpersonal and communication skills
- Effective organizational and planning skills
- Basic proficiency with computerized information systems
- French language is an asset
- Must have a valid driver’s license and access to a vehicle.
- Able to communicate with clients’, their families, and other relevant individuals in order to follow through with care plan directives
- Demonstrated awareness of cultural diversity, as well as ability to behave discreetly and sensitively to confidential issues.