Job Description

Our Nurses Sleep Better
We help you sleep easy with a supportive team, flexible schedules, paid training, and competitive pay!
Joining SE Health was the best career decision I've ever made. The people are really nice, and I was free to pick up my children after school every day. I've also had many opportunities to grow and practice to my full scope." - Mary, 20 years at SE Health
Join the FLA OHT Home Care Modernization Team in the Kingston area and play a key role in shaping the future of homecare across Ontario! We're looking for passionate care team members to fill a unique dual role that combines direct care with care integration and administrative responsibilities. If you're committed to delivering person-centered care, improving coordination and connections for client across the continuum of care, enhancing communication, embracing self-scheduling, and adapting care plans in real-time based on client needs and risks, we want you on our team. Our goal is to improve health outcomes for clients by ensuring they receive the right care, at the right time, in the right way. In this role, you'll not only provide hands-on care and integrate support around your clients, but also take an active role in planning, advocating, and driving the overall care strategy.
JOB SUMMARY:
As a Health and Social Care Integrator, you will provide exemplary leadership to home and community care teams caring for clients who are at greatest risk of hospital admission, ED visits or long-term care admission, as well as their family and friend caregivers. HSCIs manage relationships and collaborate with care coordinators specifically assigned to primary care patients and collaborate with primary care physicians and allied health professionals and a full range of community support agencies and programs to the aim of helping clients successfully remain at home for as long as possible. Additionally, this position be involved in quality improvement initiatives to ensure key performance targets are met.
RESPONSIBILITIES:

• Upon client's referral and in collaboration with clients and caregivers, prepare initial care plans addressing clients' most immediate concerns and needs, and, when interRAI HC assessments are available, contribute to the development of Coordinated Care Plans for clients and caregivers, with their collaboration.
• Advocate for, and organize access to, necessary care, supports and services for clients and caregivers to enable them to live and age well at home.
• Review and interpret InterRAI HC assessments and the resulting care plans to ensure holistic client goals and needs are being met, including reductions in the risk of hospital admission, ED visits and long-term care admission.
• Lead, coach and support interdisciplinary teams to ensure safe, effective and efficient care for clients and caregivers in collaboration with care coordinators, community support agencies and programs, primary care physicians and allied health professionals.
• As part of the interdisciplinary care teams, provide in-home care for clients and caregivers to maintain consistent contact with clients and caregivers; finetune the day-to-day, week-to-week, month-to-month care and supports by a broad team of in-home home care providers and community support services; and provide relevant information to primary care providers and allied health professionals about their patients.
• Provide on-call support and act as the main contact for care integration and communication with clients and families. Manage health human resource utilization and work collaboratively with the program manager to ensure that the optimal skill mix is available on the care team to enable the care that clients require to live and age well at home.
• Address adverse events, conduct risk investigations, and develop risk management strategies following established policies and procedures.

REQUIREMENTS:

• Minimum of 5 years of clinical RN experience.
• Completed, in-progress, or willing to take oncology certification from a recognized educational institute such as DeSouza Institute
• Completed or in-progress at least one of the following palliative certifications: LEAP, Fundamentals or CAPCE.
• Clinical expertise in home and community care, with preferred experience in Seniors Care, Oncology, Palliative Care, and Wound Care.
• Knowledge of health and social care systems, including primary care, hospital discharge planning processes and community support services.
• Technologically savvy, with proficiency in Microsoft Office and collaboration tools.
• Adaptable to fast-paced environments and able to work on-call after hours.
• Must have a vehicle, a valid driver's license, and the ability to travel.

About SE Health
SE Health is a not-for-profit social enterprise advancing health with heart. With 115+ years of impact, we bring hope, happiness and exceptional care to people and communities across Canada. We lead with empathy, dignity and purpose while building a future where everyone can realize their full health and well-being potential. We're also an inclusive, supportive workplace offering competitive compensation, strong benefits and real opportunities to grow. We're All In Together.
COVID-19: To protect the health of our clients, teams, and communities, all SE Health employees must be fully vaccinated (two doses, 14+ days since the final dose).
Accessibility: If you require accommodations due to illness or disability, please contact Talent Acquisition at .
AI and compensation details:
We use AI to take notes during our interview. All applications and interviews are reviewed by our Talent Acquisition team. This role is a replacement position. The hiring pay range is $41.00-$45.00 Paid Per Hour and based on experience.

Skills Required