Job Description

Increasingly, effective transitions between hospital and home are recognized as critical to achieving good outcomes for individuals and avoiding re-hospitalization.

Research into care transition demonstrates that the risk of readmission to hospital when people receive their first homecare nursing visit within 24 hours of discharge is significantly lower. Similarly, findings indicate post-discharge individuals who have a Primary Care visit within seven days from discharge have a significantly lower probability of readmission back to hospital.

What will you do:

Reporting to the Senior Manager, Clinical Care Programs, Mobile Emergency Diversion Nurse is responsible to ensure that improved transitions from hospital to home are optimized and that linkages to primary care teams are established. This position will provide acute clinical care treatments to patients discharged from hospital and/or community requiring nursing intervention to support discharge to home and/or prevent avoidable emergency department visits. Additionally, this position focuses on remote monitoring of adults and seniors following acute post-surgical procedures and chronic disease to ensure improved transitions from hospital to home are optimized with appropriate linkages to primary care teams are established.

This role is based on a collaborative model of care that focuses on enabling the patient to better manage their chronic disease through the support of clinical monitoring and coaching as well as post-acute surgical procedures. This will assist in prevention of post-operative complications and chronic disease management

KEY ACCOUNTABILITIES:

1. Work with interdisciplinary Point of Access team to triage patients requiring acute nursing treatments to facilitate discharge from hospital and/or assist community patient with such treatments to avoid admission to acute care/ED when contracted Service Provider Organizations are unable to provide the necessary treatment;

2. Confirm the patients\' hospital discharge care plans, complete a nursing physical assessment, administer the treatment required including but not limited to: Peripheral intravenous care, wound care, subcutaneous, intramuscular injection, medication reconciliation/medication management; chronic disease management education, assist with connection to primary care, and provide the clinical care and health education required to safely transition the patient through this high-risk period of ED return;

3. Practicing safe and competent care based on the RN scope of practice;

4. Provide support to the patient and care coordinator by providing comprehensive system navigation, ensure available HCCSS services and community services are reviewed and ensure linkage to community Care Coordinator;

5. Inform and support the community Care Coordinator in developing the patient\'s care plan and ensuring a smooth transfer of the primary care physician and pharmacist to the ongoing care team;

6. Work with contracted Service Provider Organization to transfer accountability of care when required

7. Assess for and promote a safe environment for patients, caregivers, family members, and staff;

8. Ensure contact with primary care provider, providing an update on the patient\'s acute care event and post discharge regime;

9. Participates in and demonstrates an understanding of quality, risk and patient safety principles and practices;

10. Assists with the orientation of new staff/students and carries out preceptor responsibilities as required;

11. Assist patients in establishing and implementing self-management goals;

12. Support patients in medication awareness and management;

13. Monitor patients and respond to alerts using established clinical protocols and guidelines;

14. Respond to patient phone/email inquiries and determine clinical next steps;

15. Deliver patient education using validated educational tools and resources;

16. Conduct regular and just-in-time health coaching sessions with patients;

17. Works collaboratively with team members to provide timely triage of referred patients using standardized tools and processes; and

18. May be required to perform other duties as assigned

What must you have?

• University degree in Registered Nursing
• Registered Nurse in good standing with the College of Nurses of Ontario
• Completion of Critical Care Course in area of specialty an asset
• Hold current CPR-Level C & AED certification
• A valid driver\'s license and access to a vehicle is required

• Minimum of five (5) years of relevant experience as a Registered Nurse, with recent clinical/acute experience preferred;
• Emergency/critical care and community nursing experience an asset;
• Demonstrated knowledge, experience and ability to care for patients with the following: initiation and maintenance of IV therapy, intermate/CADD pump, vascular access device management, palliative pain and symptom management, wound management skills;
• Working knowledge of community resources, the consultation process, program planning and crisis management
• Experience executing infection control practices
• Minimum of 2 years of relevant experience (pediatrics or geriatrics) as a Registered Nurse
• Proficiency with computerized information systems
• Excellent knowledge of health care related legislation and practices
• Working knowledge of the nursing process, the consultation process, program planning and crisis management.

What would give you the edge?

• Emergency/critical care experience an asset.
• Community nursing an asset.
• Completion of Critical Care Course in area of specialty an asset.
• CNA certification in an area of specialty an asset.
• Fluency in a second language an asset.

Hours of Work

Staff will work extended hours shifts: 0800 - 1900, 7 shifts in a two week period including weekends (70 hours per bi-weekly pay period).

Candidates must be flexible to adjust to shifts within the hours of operation.

The MED Nurse will participate within the on-call rotation with other RRN / EDRR Nurse team member to provide virtual consultations for patients.

Position Location and Travel

The position involves travel throughout the Central East region. A valid Ontario driver\'s license and access to a reliable vehicle is required.

Additional Information:

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.

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