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Ontario Health atHome

Provincial coordinator of home and community care

Nurse Practitioner - Regional Palliative Consultation Team

Advanced Practice ProvidersConfirmed live in the last 24 hours
ContractOttawa, ON, CanadaCA$59.86 - CA$69.52

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.

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 near end of life; liaise with patients, families, and health care providers; conduct clinical assessments, monitoring, and management; help patients manage pain and symptoms and 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’ physicians and community partners to address patient needs and goals.
  • Provide health promotion and education to Specialty Program patients using methods tailored to their needs.
  • Educate patients on disease prevention and prevention of further disability.
  • Conduct focused assessments based on intake team notes, Care Coordinator communication, manager escalations, or identified barriers, and provide recommendations to the Care Coordination team.
  • Provide consultation and support to Ontario Health atHome Champlain Care Coordinators and stakeholder partners.
  • Bring ideas and opportunities to Specialty Program leaders for discussion and consideration to support best practices.
  • Assist with collaborative development and implementation of Ontario Health atHome Champlain policies and procedures and joint initiatives with community partners.
  • Act as a Specialized Program advocate as required, and support positive public relations and service coordination through ongoing liaison and participation on internal and external committees.
  • Participate in professional development activities, including academic rounds and educational events.
  • 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 their questions.
  • Contact primary care physicians to update them about acute care events and post-discharge regimens, 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 Care Coordinators to facilitate home assessment visits; in some situations, complete in-hospital assessments and facilitate services.
  • Inform and support Care Coordinators in developing patient care plans and ensuring a smooth transfer to the primary care physician and pharmacist on the ongoing care team.
  • Answer patient and caregiver questions or concerns.
  • Act as a spokesperson as required and explain Ontario Health atHome’s role to patients, health care professionals, and the public; support positive public relations and service coordination through liaison and committee participation.
  • Promote a safe environment for patients, caregivers, family members, and staff, and follow health and safety policies and practices.
  • Participate in establishing, maintaining, and monitoring case management standards, including committee work and contributions to quality initiatives.
  • Work Monday to Friday, 8:30 a.m. to 4:30 p.m. (35 hours per week), with rotating 24/7 on-call duties.
  • 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 care providers.

About the Company

Ontario Health atHome

Provincial coordinator of home and community care

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
Not listed
Total funding
Not listed
Headquarters
Not listed
Founded
2024

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