Job Description

The Acute Care Transitions Program ensures seamless, compassionate care as patients move from hospital to home. Designed to support both patients and their families, the program connects individuals with community-based healthcare providers, social support services, primary care and acute care teams. Together, they create personalized plans that improve outcomes and ease the transition to home.
POSITION SUMMARY:
We are seeking a dynamic and passionate Registered Practical Nurses (RPN) who wants to be part of the transformational change in home and community care by providing care in a truly client-centered approach. You are excited about working in an environment that puts the care team in the driving seat; being part of a self-directed team that offers a high level of professional autonomy and responsibility. You will be part of a diverse care team that will provide services to a roster of clients in the community. You be part of a collaborative team that will conduct joint care planning with a focus on client-centered goals addressing clientxe2x80x99s physical, cognitive, social, emotional, and spiritual domains, creating a holistic care plan. Each client is assigned a primary care clinician, a member of the interdisciplinary team who will lead care planning for that client and facilitate interdisciplinary team to reach clientxe2x80x99s care goals. As part of the SE Transitions team, you will be a part of the team that will be accountable for the care and services you provide and the outcomes your clients achieve.
Full time permanent role - guaranteed 37.5 hours a week with 12 hours shifts
RESPONSIBILITIES:

• Provision of comprehensive care in an interdisciplinary team
• Primary contact for a client when designated as the primary care provider/clinician for the clientxe2x80x99s interdisciplinary team
• Provide continuous and comprehensive support to your team in the delivery of care for your clientxe2x80x99s
• Complete a client assessment and develop an interdisciplinary care plan based on best evidence/practices and on clientxe2x80x99s unique needs.
• Lead the care planning process and work with other disciplines to complete and implement interdisciplinary client care plans
• Facilitate regular interdisciplinary team communication (e.g. huddle, rounds, status updates) when designated as the primary care provider/clinician
• Lead discharge and transition care planning discussions during regular integrated team meetings with their front-line staff when designated as the primary care provider/clinician
• Facilitate and organize family and caregiver meetings
• Support the client through care transitions by collaborating and connecting the client with community support services in their local community.
• Support clients, families and caregivers to develop strong self-care strategies, anticipate and address health issues, as well as optimize their health through effective health promotion strategies

• Registered in good standing with the College of Nurses of Ontario
• Minimum of two years of nursing experience
• Experience in one of the following areas: home/community care, acute care, chronic disease management, health promotion, palliative care and mental health
• Having diverse nursing experiences with different client groups will be an asset
• Community experience is an asset.
• Demonstrated clinical leadership experience
• Enthusiasm and love of community rehabilitative care and interest in sharing knowledge
• Excellent assessment skills and a strong clinical background
• Ability to be flexible and adaptable with excellent organizational skills
• Ability to take initiative and adaptable to rapidly changing demands
• Excellent interpersonal, communication (oral and written) and critical thinking skills
• Demonstrated skills working independently and in a team environment
• Excellent skills in case management and working with/coordinating interdisciplinary care teams
• Vulnerable sector check (current).
• A vehicle and valid driverxe2x80x99s license and the ability to travel.