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.
POSITION SUMMARY:
We are seeking a dynamic and passionate Registered Nurses (RN) who wants to be part of the transformational change in home and community care by providing care in a truly client-centered approach. You are excited about working in an environment that puts the care team in the driving seat; being part of a self-directed team that offers a high level of professional autonomy and responsibility. You will be part of a diverse care team that will provide services to a roster of clients in the community. You be part of a collaborative team that will conduct joint care planning with a focus on client-centered goals addressing client’s physical, cognitive, social, emotional, and spiritual domains, creating a holistic care plan. Each client is assigned a primary care clinician, a member of the interdisciplinary team who will lead care planning for that client and facilitate interdisciplinary team to reach client’s care goals. As part of the SE Transitions team, you will be a part of the team that will be accountable for the care and services you provide and the outcomes your clients achieve.
Full time permanent role - guaranteed 37.5 hours a week with 12 hours shifts
Why join our team?
- Competitive Total Rewards. So much more than a paycheque! Enjoy comprehensive benefits, pension, on-demand pay, car loan support, supportive housing and exclusive staff perks.
- Growth That Meets Your Ambition
Build your skills with education bursaries, tuition support, ongoing training and mentorship. Our leadership team is available 24/7 to help you practice to full scope and deliver excellent care. With diverse roles and locations across Canada, you’ll have opportunities to explore new career paths or move into support and leadership positions. - Innovative. At SE, we are always looking for new, innovative ways to improve. You’ll be encouraged and supported to identify and make improvements to the way we do our work. As a social enterprise, we support research into Senior’s Health and Aging.
- Purpose & Impact
Join a national social enterprise where your voice matters. Every role helps advance health, spark innovation and strengthen communities across Canada. - Manage your life. At SE, you’ll be supported with the time you need to meet the needs of your clients and meet your own needs, develop yourself and your career, and be part of a team.
- Support to be your best. At SE you are afforded the time you need to help patients, to build rapport, to accomplish patient care and recovery goals, and to understand the home and life environments that impact recovery in a way you can’t in most other settings. At SE, you meet your patients where they are, and together you take them to new heights
RESPONSIBILITIES:
- Provision of comprehensive care in an interdisciplinary team
- Primary contact for a client when designated as the primary care provider/clinician for the client’s interdisciplinary team
- Provide continuous and comprehensive support to your team in the delivery of care for your client’s
- Complete a client assessment and develop an interdisciplinary care plan based on best evidence/practices and on client’s unique needs.
- Lead the care planning process and work with other disciplines to complete and implement interdisciplinary client care plans
- Facilitate regular interdisciplinary team communication (e.g. huddle, rounds, status updates) when designated as the primary care provider/clinician
- Lead discharge and transition care planning discussions during regular integrated team meetings with their front-line staff when designated as the primary care provider/clinician
- Facilitate and organize family and caregiver meetings
- Support the client through care transitions by collaborating and connecting the client with community support services in their local community.
- Support clients, families and caregivers to develop strong self-care strategies, anticipate and address health issues, as well as optimize their health through effective health promotion strategies
REQUIREMENTS:
- Registered in good standing with the College of Nurses of Ontario
- Minimum of two years of nursing experience
- Experience in one of the following areas: home/community care, acute care, chronic disease management, health promotion, palliative care and mental health
- Having diverse nursing experiences with different client groups will be an asset
- Community experience is an asset.
- Demonstrated clinical leadership experience
- Enthusiasm and love of community rehabilitative care and interest in sharing knowledge
- Excellent assessment skills and a strong clinical background
- Ability to be flexible and adaptable with excellent organizational skills
- Ability to take initiative and adaptable to rapidly changing demands
- Excellent interpersonal, communication (oral and written) and critical thinking skills
- Demonstrated skills working independently and in a team environment
- Excellent skills in case management and working with/coordinating interdisciplinary care teams
- Vulnerable sector check (current).
- A vehicle and valid driver’s license and the ability to travel.
About SE Health
SE Health is a not-for-profit social enterprise advancing health with heart. With 115+ years of impact, we bring hope, happiness and exceptional care to people and communities across Canada. We lead with empathy, dignity and purpose while building a future where everyone can realize their full health and well-being potential. We’re also an inclusive, supportive workplace offering competitive compensation, strong benefits and real opportunities to grow. We’re All In Together.
COVID-19: To protect the health of our clients, teams, and communities, all SE Health employees must be fully vaccinated (two doses, 14+ days since the final dose).
Accessibility: If you require accommodations due to illness or disability, please contact Talent Acquisition at careers@sehc.com.
AI and compensation details:
We use AI to take notes during our interview. All applications and interviews are reviewed by our Talent Acquisition team. This role is a replacement. The hiring pay range is $37.00 - $43.50 per hour, based on experience.