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Ontario Health atHome

Provincial coordinator of home and community care

Nurse Practitioner - Regional Palliative Consultation Team

ContractDeadline 10/8/27
CA$59.86 - CA$69.52
Mid
Ottawa, ON, Canada
In Person
Medical, Clinical & VeterinaryAdvanced Practice Providers

About the job

Requirements
  • Membership in good standing with the College of Nurses of Ontario.
  • Registered Nurse in the Extended Class (RN EC designation).
  • Working knowledge of community resources and the roles of health care professionals.
  • Review discharge care plans and confirm outstanding medical tests have been scheduled and transportation is available.
  • Conduct medication reconciliation, review medication protocols with patients and caregivers, and answer questions.
  • Initiate contact with the primary care physician to provide updates on acute care events and post-discharge regimes, and facilitate a one-week follow-up visit with the physician where appropriate.
  • Identify patients requiring accelerated assessment and home care services, and work with the Care Coordinator to facilitate a home assessment; in some situations, complete an in-hospital assessment and facilitate services as required.
  • Inform and support the Care Coordinator in developing the patient’s care plan and ensuring a smooth transfer of the primary care physician and pharmacist to the ongoing care team.
  • Answer questions or concerns from patients and caregivers.
  • Act as a spokesperson as required and interpret the role of Ontario Health atHome to patients, health care professionals, and the public.
  • Assess for and promote a safe environment for patients, caregivers, family members, and staff, and adhere to health and safety policies and practices.
  • Participate in establishing, maintaining, and monitoring Case Management standards, including committee work and active contribution to quality initiatives.
Responsibilities
  • Provide holistic patient care based on advanced nursing and basic medical management knowledge and skills for a selected patient population.
  • Provide care for medically complex patients and palliative care for patients in their homes as they near end of life.
  • Liaise with patients, families, and health care providers, using clinical assessment, monitoring, and management skills to provide patient care.
  • Help patients manage pain and symptoms, avoid unnecessary hospitalization, and manage acute and episodic complex disease.
  • Deliver comprehensive primary health care services, including medication reconciliation, prescribing medication, ordering laboratory work, chart reviews, and physical examinations, to at-risk adults and seniors facing barriers to health care access.
  • Liaise with patients’ existing physicians and community partners as needed to address patient needs and goals.
  • Provide health promotion and education to patients in Specialty Programs using methods tailored to each patient’s needs.
  • Educate patients on disease prevention and prevention of further disability.
  • Conduct focused assessments based on intake team notes, Care Coordinator communications, or manager escalations or barrier identification, and provide recommendations to the Care Coordination team.
  • Provide consultation and support to Ontario Health atHome Champlain Care Coordinators and key stakeholder partners.
  • Bring ideas and opportunities to Specialty Program leaders to support best practice dialogue and consideration.
  • Assist with collaborative development and implementation of Ontario Health atHome Champlain policies and procedures and joint initiatives with community partners.
  • Act as a Specialty Program advocate as required and support effective service coordination through ongoing liaison and participation on internal and external committees.
  • Participate in professional development activities, including academic rounds and other educational events.
  • Perform other related duties as assigned.
Desired Qualifications
  • Fluency in English and French is an asset.
  • Specialized education in palliative pain and symptom management.
  • Palliative or end-of-life care experience.
  • Awareness of Medical Assistance in Dying legislation.
  • Complex chronic disease management and psychogeriatric care experience.
  • Advanced assessment skills and sound knowledge of clinical therapeutics.
  • Demonstrated clinical leadership and collaborative practice with all care providers.

About the company

Ontario Health atHome coordinates in-home and community-based care for patients across Ontario and manages access to long-term care home placement. Its teams assess care needs, arrange services, and connect patients and caregivers with nursing, personal support, rehabilitation, and other community resources. The organization works with hospitals, primary care providers, Ontario Health Teams, and contracted service providers to plan care and support transitions between settings. It also helps people find health and social services, navigate supportive living options, and receive palliative care in their chosen setting. The agency was formed in June 2024 by amalgamating the fourteen Home and Community Care Support Services organizations.

Company Size

5,001-10,000

Company Stage

N/A

Total Funding

N/A

Headquarters

N/A

Founded

2024

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