Visiting Nurse - Hospital to Home Program

Colonial Group; Toronto; Hybrid; CAD 65,000 - 88,000; Full time

Benefits offered by this job

Paid time off (vacation, personal, and

Health and dental benefits

RRSP program with RBC

Job summary

Colonial Group is seeking a Full-Time Visiting Nurse to support patients in community settings across central and west Toronto. The role involves visiting patients in their homes, coordinating care with hospital teams, and participating in weekend and holiday rotations.

The position requires travel within the community and adherence to nursing standards, with a strong focus on patient-centered outcomes and care transitions.

Qualifications

• Registered nurse with current CNO registration.
• Experience in home/community or hospital with elderly population.
• Commitment to evidence-based clinical practice and outcomes.
• Excellent communication and collaboration skills.
• Must have a valid driver’s license and access to a vehicle.
• French language proficiency is an asset.

Responsibilities

• Establish trust with patients and families to understand care goals.
• Facilitate hospital-to-home transitions with supportive care.
• Complete in-home assessments and develop care plans.
• Complete medication reconciliation and InterRAI-HC assessments.
• Provide nursing interventions including IV therapy and wound care.
• Document care per standards and liaise with hospital team.
• Coordinate with community partners for transitions.

Skills

Communication skills

Interpersonal skills

Problem solving

Organizational skills

Driver's license

French (asset)

Independent work

Education

Registered Nurse or Registered Practical Nurse with CNO registration

Tools

Inter-RAI tools

Microsoft Office

Job description

Job Description

We are looking for: A Full-Time, Permanent Visiting Nurse

Hours of Work:

Monday - Friday 8:30AM - 4:30PM. Requirement to be part of weekend and holiday rotation.

Location:

This role requires travelling in the community. Generally within central and west Toronto.

Reports to:

Manager, Hospital to Home and Clinical Programs

Compensation & Benefits

Salary Range:

The salary for this role ranges from $65,000 to $88,000 per year, depending on your skills and experience.

On top of a competitive base salary, we support rest and overall wellness through generous paid time off for vacation, personal and sick days.

Circle of Care Benefits:

Health and Dental Benefits:

A robust benefits plan with comprehensive health, dental, paramedical and vision coverage with employer paid premiums to support you and your family through all stages of life.

Retirement Savings Plan:

As part of our commitment to your long-term well-being, we provide an RRSP program through RBC with employer and voluntary employee contributions.

Learning and Development:

We support your continued growth and learning through paid training and professional developmentopportunities throughout your career.

Responsibilities

Nursing

• Establish trust and respect with patients/family to understand their goals and preferences for care.
• Facilitate a smooth transition from hospital to home by providing supportive, non-judgmental care and guidance throughout the process.
• Review the Patient Service Plan, plus the Referral Information Package for the reason for hospitalization, surgical procedures, past medical history, list of diagnoses, reportable signs and symptoms, medical orders for nursing, follow-up appointments, and list of discharge medication.
• Conduct comprehensive assessments of patient needs and connect them with primary care providers and relevant services such as PT, OT, PSS, SW, RD, SLP.
• Accept patient referrals from the hospital, clarify any questions with the Manager, and liaise with hospital care team as needed to identify barriers to care
• Collaborate with patients to overcome transition challenges, ensuring they receive the appropriate support for their well-being.
• Deliver supportive health education, including chronic disease self-management strategies, to patients dealing with complex or chronic health conditions.
• Maintain accurate, timely, and thorough professional documentation of patient interactions, care plans, and progress as per CNO standards and Circle of Care policies.
• Initiate transition planning throughout service and work closely with community partners, such as Ontario Health at Home for a warm handoff.
• Promote needs-based, ethical practices, and health equity in recommending professional services and social prescribing for patients.
• Review the supply inventory available in the patient’s home and report any gaps or needs to the Manager to ensure adequate supplies are available for ongoing treatment.

Conduct In-Home Client Assessments

• Complete in person community visits at patients’ home.
• Provide ongoing assessment/reassessment of patients’ and their need for service according to program and organizational guidelines.
• Develop care plans based upon patient involvement to optimize their health and functional status.
• Complete medication reconciliation on admission and discharge.
• Complete InterRAI-HC tool for each patient prior to their discharge from the program.
• Ensure all necessary documentation is completed and required consents are obtained. Return all healthcare records to the office following the patient’s discharge from the hospital, following the Records Management return process.
• Submit Professional Service Reports within three days of the initial visit and submit Transition/Discharge Reports as requested or within 7 days of discharge.
• Perform treatment-based interventions as required, including but not limited to: IV therapy, wound care, catheterization, and medication administration. All interventions must fall within the scope of nursing practice and be based on physician orders.
• Advocate on behalf of the patient to ensure their needs are met.
• Complete initial and follow-up goal achievement, with patient/caregiver input.
• Participate in case conferences and huddles.
• Maintain regular contact with Manager and Service Coordinators.
• Use motivational interviewing with patients and families and engage patients and families in partnership using empathy to manage frustration and escalation.
• Provide after-hours support to patients and their families as needed.

Monitor/Training Personal Support Workers

• Carry out delegation or shadow visits for Personal Support Workers.
• Ensure PSWs are informed of patient risk factors to support safe care.
• Communicate effectively to ensure the team is aware of changing patient needs and information.
• Monitor impact of PSW care when visiting patients.

• Provide training and follow-up on Special Functions such as oral medication, safe moving and handling, mechanical lift training review, skin health, emptying urinary catheter drainage systems, emptying ostomy appliances.

• Provide direction to PSWs during crisis situations/urgent visits such as medical emergencies.
• Follow all policies/procedures regarding the role of PSWs, health and safety of patients and PSWs while providing care.
• Monitor for patient falls risks and promote safe moving and handling as per evidence informed standards.

Team effectiveness and service development

• Participate in H2H huddles and transition meetings at regular intervals.
• Support program requirements and timelines.
• Work collaboratively with external stakeholders, hospital partners, and internal team.

Weekend Rotation

• Nurses are required to work weekends in rotation with Visiting Nurse team and complete a holiday rotation, depending on team size. During weekend/holiday shifts, nurses will be scheduled to see patients according to standard practice. Urgent visits will be incorporated into the weekend rotation to ensure timely patient care.
• Participate in the weekend rotation as per the Master Schedule.
• Nurses working on the Weekend Rotation will receive a Transfer of Accountability Report via email or phone message from the patient’s Primary Nurse before initiating nursing care.
• Weekend visits will be scheduled by the Service Coordinator and may include visits to provide treatment such as wound care, comprehensive assessment, catheter insertion, Medication Administration Oral/IV, based on patient needs.
• Conduct teaching visits for PSWs or shadow visits that cannot be completed during business hours to oversee PSWs working evening shifts.
• Prioritize patients admitted to the program, who are obligated to receive nursing visits during the first seven days of admission.

Risk, Health and Work Place Safety

• Identifying and reporting health and safety incidents and concerns in a timely manner as per policy.
• Participating in health and safety processes and procedures.
• Participating in maintaining a safe workplace environment by cultivating a positive safety culture and encouraging best practices to promote both staff and client safety and well-being.
• Participating in all health and safety training initiatives on a regular basis.
• Taking proactive action against patient incidents within scope of practice.
• Developing a plan to identify, manage and/or minimize patient safety risks or situations in adherence with risk management operations policies.
• Assessing the severity of an adverse patient safety/risk event and determining the best follow-up and developing an action plan following the event.
• Evaluating any potential hazards and identifying patients at risk for adverse health and safety events, taking preventative measures when necessary to minimize reoccurrence.
• Reporting all safety events impacting patients, caregivers and families in a timely and honest disclosure.

Qualifications

• Registered Nurse or Registered Practical Nurse with current registration with CNO.
• Experience working as part of an integrated team with knowledge of regulated and unregulated health care providers.
• Experience working in home or hospital with elderly population or in community-based care.
• Commitment to evidence-informed clinical practice, outcome measures, professional practice models, and CNO practice requirements in Ontario.
• Commitment to person-centered care and cultural diversity.
• Knowledge of population health and vulnerable populations (elder adults, Indigenous people, people living with mental health and addictions, LGBTQ+).
• Excellent knowledge of the social determinants of health, impact on clinical outcomes.
• Knowledge of safe moving, handling, and other environmental home safety hazards.
• Experience in patient assessments involving personal support to ensure quality outcomes.
• Knowledge of home safety equipment used in home care and funding/ordering procedures.
• Knowledge of medical supplies used in home care for wound care and other needs.
• Commitment to evidence informed clinical practice and outcome measures, professional practice models and professional college practice requirements in Ontario.
• Excellent oral/written communication and collaboration skills.
• Ability to work in a fast-paced setting with excellent problem-solving and assessment skills.
• Excellent interpersonal, problem-solving, and communication skills.
• Highly organized, able to work independently.
• Competency in Inter-RAI tools and Microsoft Office.
• Must have a valid Drivers License and access to a vehicle.
• French language proficiency is an asset.
• Flexibility in schedule, required to be on-call for additional program support as needed.