The Acute Care Transitions Program ensures seamless, compassionate care as patients move from hospital to home. Designed to support both patients and their families, the program connects individuals with community-based healthcare providers, social support services, primary care, and acute care teams. Together, they create personalized plans that improve outcomes and ease the transition to home.
Job Summary:
The Nurse Practitioner (NP) provides comprehensive, person-centered care within a home- and community-based transitional care program. Practicing to the full scope of the NP role, they work as part of an interdisciplinary team to support patients with complex medical, functional, and psychosocial needs during critical transitions in care.
Reporting to the Regional Director and collaborating closely with the Clinical Transitions Manager, the NP is responsible for clinical assessments, diagnosis, prescribing, and care planning for a primarily older adult population with chronic conditions, complex comorbidities, cognitive impairment, mental health needs, or requiring rehabilitative support. The NP plays a key role in improving care continuity, reducing unnecessary emergency visits, and enhancing outcomes across the care continuum.
This is a hybrid role based in the London area, with a mix of virtual and in-person care delivery depending on patient needs. The in-person component of the role will support patients and teams in the local area, while the virtual component may provide care and consultation support to programs across the province.
Hybrid opportunity supporting SouthWestern Ontario and GTA
Key Responsibilities:
1. Clinical Care and Case Management
· Provide tiered involvement based on clinical judgment—from one-time consults to longitudinal follow-up throughout the patient’s time in the program.
· Conduct comprehensive assessments, order and interpret diagnostics, diagnose, prescribe medications, and implement therapeutic plans of care.
· Support patients experiencing acute exacerbations or complex health challenges, including geriatric syndromes, cognitive impairment, and mental health.
· Collaborate with the community interdisciplinary team to support care escalation and maximize scope of practice across disciplines.
· Act as a liaison with primary care providers, specialists, and other community services to ensure coordinated care.
· Support safe transitions in and out of the program, with emphasis on reducing hospital readmissions and avoidable ED/walk-in visits.
· Offer timely interventions when primary care is delayed or unavailable.
· Provide clinical leadership in advance care planning, symptom management, and palliative approaches as appropriate.
2. Collaboration and Interdisciplinary Support
· Work as part of an integrated, interdisciplinary care team to develop and implement care plans that are patient-centered and goal-oriented.
· Share expertise and clinical insight to support other providers, particularly in complex or ambiguous situations.
· Promote a team-based, high-trust environment aligned with the H.O.P.E. Model™ of care.
3. Quality Improvement and Program Development
· Contribute to continuous quality improvement by identifying gaps, trends, and opportunities to enhance patient outcomes.
· Collaborate with the Clinical Transition Manager, Transitions Care Lead, and others to monitor performance indicators.
· Participate in program evaluation and support implementation of best practices and innovations.
Qualifications:
· Current registration with the College of Nurses of Ontario in the Extended Class (NP-Adult or NP-Primary Health Care).
· Master's Degree in Nursing/Nurse Practitioner, or MScN with post-Master’s NP diploma.
· Minimum of 2 years of clinical experience in primary care, home and community care, chronic disease management, transitional care, palliative care, or mental health.
· Demonstrated ability to work autonomously and exercise sound clinical judgment within full NP scope.
· Proven experience managing complex patients and collaborating with interdisciplinary and primary care teams.
· Strong clinical reasoning, problem-solving, and communication skills.
· Comfort working in a dynamic, evolving care environment with virtual and in-person components.
· Familiarity with EMRs and digital care delivery tools.
· Vulnerable Sector Check required.
· Some travel may be required to support in-person care delivery.
About SE Health
At SE, we love what we do. Every day, we bring hope and happiness to clients, homes, and communities across Canada. We treat each person with dignity and love, like our own family; we build empathy; and we do the right thing. We are always inspired to make a difference. As a not-for-profit social enterprise, we share knowledge, provide the best care, and help each client to realize their most meaningful goals for health and wellbeing. We are an inclusive workplace offering competitive pay, benefits, pension, and work life balance. We’re a great place to work, and we hope you’ll join our team.
In the interest of the health and safety of our patients/clients, employees, and greater good of public health, SE Health requires those who wish to work for this organization to be fully vaccinated against COVID-19. Fully vaccinated means a person has received both doses of the COVID-19 vaccine and it has been 14 days since the last dose.
SE Health is committed to the success of all its employees. If you feel you need accommodations because of illness or disability, please do not hesitate to contact the Talent Acquisition team at careers@sehc.com at your earliest convenience