Nurse - Hospital to Home Program

Spectrum Health CareScarborough, ON, CA

6 days ago

Job type

Full-time

Job description

Company Description

Spectrum Health Care is looking for a dedicated and experienced Registered Nurse (RN) or Registered Practical Nurse (RPN) eager to support health system change and improve transitions for patients from hospital to home in Scarborough . This role will support Scarborough Health Network's (SHN) strategy to enhance patient transitions from hospital to home through an established Emergency Department (ED) Transition Pathway. This innovative program aims to reduce hospital admissions and improve the transition from the emergency department to the community for older adults with complex or chronic conditions.

The position involves collaborating with the GEM Team to assess patient needs, develop individualized care plans, and collaborating with the team which includes unregulated health providers ( PSW’s) and rehabilitation supports such as physiotherapy or occupational therapy. You will also deliver direct and or virtual home health nursing care in alignment with the College of Nurses of Ontario Practice Standards, Spectrum Health Care policies, and community health nursing best practices. Additionally, you will serve as a key point of contact between the hospital, patients, families, and community resources to optimize patient outcomes and reduce the risk of readmission.

Job Description

Assist GEM team with coordinating the intake process, planning patient care needs and services provided by Spectrum Health Care’s multidisciplinary team.
Monitor the services and status of the patients from intake to discharge, and discuss patient progress with GEM team, highlighting cases that require attention or intervention.
Conducts a comprehensive and collaborative health assessment to determine the health status, functional and psychosocial needs of the client and their families within the context of their environment and social supports.
Collaborates with other members of the health care team to determine and access required services
Plan and prioritize visits to meet health and scheduling needs of client.
Uses documentation as an effective communication tool ensuring that all team members are informed and updated on concerns or changes in client status. All documentation will meet the standards, guidelines, policies and procedures of Spectrum Health Care and the College of Nurses of Ontario.
Facilitate successful transition to home with a supportive non-judgmental approach through assessment, health teaching and self-management skills for patients with chronic and complex health challenges.
Support patients and their caregivers, ensuring their questions are answered, a seamless care approach is in place.
Awareness of caregiver burden and provide support as required.
Continually assesses, anticipates, identifies and responds to new and changing needs of clients.
Complete best possible medication history and medication reconciliation as identified.
Complete home safety assessment and discuss safety in the home environment with the patient / caregiver.

Qualifications

Registered Nurse (RN) / Registered Practical Nurse (RPN) with valid license and certification

Proven experience in a clinical setting working with patients faced with chronic diseases such as : dementia, CHF, COPD, diabetes.

Care coordination or community nursing experience is preferred.

Strong organizational skills with the ability to manage multiple tasks and priorities effectively.

Excellent communication and interpersonal skills, with the ability to interact empathetically with patients, families, and team members.

Knowledge of multidisciplinary care approaches and the ability to work collaboratively within a team.

Ability to adapt to changing patient needs and provide high-quality care in diverse scenarios.

Experience with outreach and supporting patients in their home environment or partnering with others to support patients / caregivers to remove barriers through their care journey

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Additional Information

Spectrum Health Care is thrilled to be named one of Canada’s Best Managed Companies. This award recognizes top companies across Canada for overall performance, sustained growth, strategy, capabilities and innovation, culture and commitment, and leadership. Click to learn more about this esteemed honour.

We thank all applicants, however, only those individuals selected for interviews will be contacted.

In accordance with the Accessibility for Ontarians with Disabilities Act 2005, upon request, support will be provided for accommodations throughout the recruitment process.

If you require accommodation because of disability through the recruitment process, please contact Human Resources at () for assistance.

Spectrum Health Care is committed to fostering, cultivating and building a culture of diversity, equity and inclusion within our organization. We strive to attract, engage and develop a workforce that reflects the diverse communities that we serve and we know a diverse workforce is key to the growth and success of our organization.