Transition Support Nurse
- Canada
- $43.46-51.52 per hour
- Temporary
- Full-time
- Plan, organize and provide timely and effective care. Confirm hospital discharge plan and liaise with hospital staff and Care Coordinator in regards to patient discharge if required
- Complete a nursing physical assessment in the patient’s home and provide health teaching to the patient and/or family regarding their illness/symptom management and avoidance of re-occurrence of acute episode.
- Review the discharge care plan and confirm outstanding medical tests are scheduled, coordinating family/friends supports as needed.
- Complete a Best Possible Medication History (BPMH) and provide teaching and medication management as required with the patient and/or caregiver. In partnership with a pharmacist, the TSN ensures new prescriptions are filled and facilitates a medication reconciliation to confirm no drug interactions or contraindications
- Ensure contact with primary care provider, providing an update on the patient’s acute care event and post discharge regime.
- Recommend and facilitate a follow up visit as appropriate
- Identify patient’s requiring an accelerated Care Coordination home assessment for home care services and work with the Care Coordinator to facilitate the home assessment visit.
- Inform and support the Care Coordinator in developing the client’s care plan and ensuring a smooth transfer of the primary care physician and pharmacist to the ongoing care team.
- Provide health teaching and information to the patient/caregiver and ensure they have Home and Community Care Support Services South East contact information
- Direct nursing care with non-complex skills for a short stay or until discharge or transition to another Direct Care Provider.
- Assess for and promote a safe environment for clients, caregivers, family members, and staff.
- Participates in and demonstrates an understanding of quality, risk and patient safety principles and practices
- Assists with the orientation of new staff/students and carries out preceptor responsibilities
- Minimum of five (5) years of relevant experience as a Registered Nurse, with recent clinical/acute experience preferred
- Holds current appropriate unrestricted registration as a Registered Nurse with the College of Nurses of Ontario
- University Degree in Nursing preferred
- Working knowledge of community resources and roles of multi-disciplinary health care professionals
- Working knowledge of the nursing process, the consultation process, program planning and crisis management
- Emergency/critical care and community nursing experience an asset
- Completion of critical care course in area of specialty an asset
- Demonstrate knowledge, experience and ability to care for patients with the following would be an asset: Initiation and maintenance of IV therapy, Intermate/CADD pump, Vascular Access Device management, Palliative pain and symptom management, wound management skills
- Hold current CPR- Level C & AED certification
- Vehicle and valid Ontario driver’s license is required
- Proficient in a Windows environment
- We have a mandatory COVID-19 vaccination policy. As a condition of employment, all employees are required to submit proof of COVID-19 vaccination status prior to start date.
- Knowledge of direct care / case management models used in community health care organizations.
- Knowledge of health care related legislation and practices
- Significant understanding of relationship with Ontario Health atHome in the area of South East and South East LTCHs, hospitals, community support service and contracted service providers.
- Practical knowledge of relevant legislation (e.g. Long-Term Care Act)
- Ability to deliver information effectively, verbally and in writing, in a variety of settings
- Ability to speak French or another second language
- Attractive comprehensive compensation packages and benefits
- Valuable development opportunities
- Membership in a world class defined benefit pension plan
- Salary: $43.46 - $51.52/hour