Nursing Agency jobs in Toronto, ON

• Coordinates services within the clients home, community, delivery and pick up of medical equipment and supplies as needed based on program-specific workflows

• Conduct occasional hospital visits to support hospital discharge planning or participate in case conferences for complex cases

• Conducts home visits with the client following program-specific timelines to complete comprehensive assessments in partnership with the program funder, client and family to inform the development client goals within the program and an individualized client care plan

• Arranges and adjusts home care services according to the care plan and in alignment with services contained within the program bundle

• Monitors appropriate service allocation and bundle management

• Attends program huddles with internal teams, hospital partners and/or program funders

• Arranges appointments and liaise with the client’s primary care provider within set program specific timelines, supports the client to connect with primary care when required

• Completes documentation after encounters with clients and their care team and communicates any risk-related events to the VHA team in a timely manner

• Completes referrals to appropriate community services when needed and facilitates a seamless and supporting transition to these services

• Provides direct care to the client and trains staff on delegated acts as required

• Monitors program metrics and participates in program evaluation and process improvement

Key skills, experience and behaviours required for this position:

• Undergraduate degree in Nursing (RN Required)

• 5+ years of experience in home and community health or a related field

• Member, in good standing with College of Nurses of Ontario

• Knowledge of the health care delivery system including hospital discharge planning, home and community care, and support services

• Excellent skills in case management, coordinating care within interdisciplinary teams, interRAI assessments and navigation of community services

• Excellent assessment and decision-making skills

• Passion for excellent customer service and customer experience

• Effective time management skills, with the ability to work independently and co-operatively in a busy multidisciplinary environment in various settings (e.g. at the hospital, in the office, in the community).

• Proficient skills in Microsoft Office (Word, Excel, PPT) and comfort with learning/working with new and emerging technologies (e.g. EHR systems, reporting systems)

• Intersectoral experience and excellent relationship building skills and dispute resolution

• Must be available for on-call support

• A valid driver’s license and access to a reliable vehicle