Job Description

CARE AND BE CARED FOR – THIS IS YOUR HOME To ensure effective transitions from acute to home care for frail adults and seniors with complex needs and/or high risk characteristics. To ensure communication and linkage with primary care; and provide timely and effective rapid response home care. The Rapid Response Nurse provides the first in-home nursing visit within 24 to 48 hours from hospital discharge. During this visit, the nurse will confirm the patient hospital discharge care plan, communicate the importance of primary care to avoid re-hospitalization, and perform medication reconciliation for the patient.

What will you do?

Ensure effective transitions from acute to home care and prevent existing patients from going to the hospital for the following target population: frail adults with complex needs and/or high risk characteristics. Ensure communication and linkage with primary care provider and provide timely and effective rapid response home care.

The Rapid Response Registered

Nurse (RN) provides the first in-home nursing visit within 24 hours from hospital discharge for high needs seniors and adults. During this visit, the RN will confirm the patient hospital discharge care plan, complete a nursing physical assessment, and communicate the importance of connection to primary care to avoid re-hospitalization. Part of the assessment includes performing medication reconciliation and assessing medication management for the patient and family. The nurse will also complete teaching with the patient, family and caregivers related to their disease and/or chronic illness regarding how to manage their symptoms and when to seek medical attention. The RN will collaborate with other members of the interdisciplinary team including care coordinators, nurse practitioners, pharmacists and contracted service providers.

Team/Department: Rapid Response

Hours of Work: Casual shifts within the hours of 8:00AM – 8:00PM, Monday – Sunday (comprising of 8-hour and/or 10-hour shifts)

FTE: 0.0

Starting Salary: $44.480/hr to $47.517/hr

Affiliation: ONA

Reporting to: Manager, Patient Services

Office Location: Labelle

What must you have?

• Review the discharge care plan and confirm that outstanding investigations have been scheduled and transportation is available. Liaise with hospital staff and care coordinator in regards to discharge plan.
• Directly or in partnership with a pharmacist, ensure new prescriptions are filled and conduct a medication review and reconciliation. Review the medication protocol with the patients and/or caregiver and provide health teaching.
• 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.
• Ensure contact with primary care provider and provide an update on the patients acute care event and post discharge regime. Recommend and facilitate a follow up visit as appropriate and/or within 7 days after discharge from the hospital.
• Refer the patient to Health Care Connect if the patient has no primary care provider
• Identify patients requiring an accelerated assessment and home care services and coordinate with the care coordinator and/or nurse practitioner to facilitate the assessment
• Collaborate with the care coordinator to develop the patient’s care plan and ensure a smooth transfer of the primary care provider and pharmacist to the ongoing care team
• Provide health teaching and information to the patient/caregiver and ensure they have the OH atHome contact information
• Act as a spokesperson as required and interpret the role of the OH atHome to patients, healthcare professionals and to the public. Ensure positive public relations and effective coordination of services through ongoing liaison and participation in internal and external committees. Assess for and promote a safe environment for patients, caregivers, family members and staff. Adhere to health and safety policies and practices developed and implemented by OH atHome
• Participate in establishing; maintaining and monitoring standards for the HCCSS direct nursing providers, including committee work and active participation and contribution to quality initiatives.
• Leads and/or participates in and demonstrates an understanding of quality, risk and patient safety principles and practices.
• Follows all safe work practices and procedures and immediately communicates any activity or action which may constitute a risk to quality, and patient safety.
• Perform other duties as assigned

Patient Safety

• Promotes patient