Registered Nurse-Hospital to Home

Are you an experienced registered nurse, physiotherapist, occupational therapist,  social worker (MSW), dietitian, or speech language pathologist seeking a rewarding career that cares for others, in a professional practice that cares for you? You’re looking in the right place.

What will you do?

• Complete a comprehensive geriatric behaviour assessment using the PIECES framework and supporting geriatric assessments.

• Liaise with members of the care teams including the patient and care provider in developing a comprehensive behavioural care plan specific to target primary behaviour at time of transition. The team includes i.e., hospital staff, LHIN staff, discharge planner, physicians, Alzheimer’s, and Psychogeriatric Resource Consultants and crisis team. etc. to coordinate and integrate care plans.
• Conducts a Best Possible Medication History and shares with members of the care team. Interacts with a member of the Pharmacy team in any setting to support medication changes and monitoring in compliance with medication management policy.
• Either directly or through the LHIN Case Manager, works collaboratively to connect with the primary care physician, geriatrician or geri-psychiatric specialist and provides updates on patient status post-discharge from hospital. Recommends and facilitates, as appropriate, follow-up visits with the primary care physician or nurse practitioner in community or Long term care home.
• Addresses and works with the client and care giver to answer questions and concerns supporting the behaviour management care plan.
• Assessment, consultation, and treatment, as indicated.
• Utilizes an ABOE ( Assessment, Behaviour, Outcomes and Evaluation approach and communicates these observations to the care team and care giver
• Documents assessments and care plan in the LHIN CHRIS database, OSLER and HEADWATERS Hospital MEDITECH database.
• Participates in data entry to track program metrics.
• Acts as a spokesperson as required, and interpret the role of the LHIN to clients, health care professionals and to the public. Ensure positive public relations and effective co-ordination of services through ongoing liaison and participation on internal and external committees.
• Participates in the orientation of new staff and students and provides refresher training for current staff as assigned.
• Assesses for and promotes a safe environment for clients, caregivers, family members, and staff. Adhere to health and safety policies/ practices developed and implemented by the LHIN/ Osler and Headwaters hospital.
• Participates in utilizing, maintaining, and monitoring Best Practice standards for the geriatric behaviour population. This includes committee work and active participation and contribution to quality initiatives.
  
  

What must you have?

• Ability to assist staff and family members in a person centred approach to develop and implement behavioural care strategies/approaches and to monitor patients responses over time
• Demonstrates commitment to the LHIN’s mission and values.
• Working knowledge of community resources and roles of health care professional
• Solid knowledge of health care related legislation and practices
• Knowledge of direct care / case management models used in community health care organizations.
•  Knowledge of LHIN priorities, policies, practices and service standards
• Registered Nurse (BScN or diploma)
• Completion of a Case Management Certificate is an asset
• Completion of P.I.E.C.E.S training and experience using this model
• GPA ( Gentle Persuasive Approach) essential
• Demonstrated experience meeting documentation standards of the College of Nurses of Ontario and organizational expectations
• Crisis Prevention Intervention Training an asset
• CNA certification in Geriatrics preferred
• Current CPR certification
• Minimum of two (2) years of experience relevant experience as a Registered Nurse (BScN or diploma) focused on providing or coordinating care for adults in a mental health setting and/or specialized geriatrics unit with experience in dementia care
• Specialized skills in assessment of delirium, dementia and mental health. Knowledge of multiple best practices in these areas
• Ongoing annual recertification BCLS/BLS or CPR - BCLS/BLS for Healthcare Provider or CPR Healthcare Provider level current
• Registered Nurse (BScN or diploma) in good standing with the college of Nurses of Ontario

What would give you the edge?

• Experience working with diverse patient groups, e.g., multicultural, homeless, palliative, acquired brain injury (ABI), mental health, geriatrics, pediatrics
• Case management experience or recent related community experience
• 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, family physicians, 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.

Equity, Inclusion, Diversity and Anti-Racism Commitment

Home and Community Care Support Services is committed to a culture of equity, inclusion, diversity and anti-racism. We are committed to attracting, engaging and developing a workforce that reflects the diverse communities we serve. We welcome and encourage applications from all qualified applicants. Accommodations for persons with disabilities required during the recruitment process are available upon request.

We thank all applicants for their interest; however, only those selected for an interview will be contacted.