Home Care Specialist (Permanent Full-Time)

If you're a Registered Nurse (RN) with CNO, this opportunity is for you!

The Home Care Specialist will provide care coordination, case management, and system navigation services to clients enrolled in the Hospital@Home, Hospital to Home and OHT-lead programs/projects and other integrated care programs. This role plays a key part in supporting clients through their transition from hospital to home and continues to provide case management throughout their participation in the program. Acting as a liaison between home care clients, hospital partners, primary care and community care teams, the Home Care Specialist ensures continuity of care and alignment with program objectives. The position also fosters strong collaboration with program funders to enable smooth, client-centered transitions, while contributing to quality improvement efforts aimed at optimizing patient flow, care coordination, and service delivery within the programs.

Key Areas of Accountability:

• Coordinates services within the clients home, community, delivery and pick up of medical equipment and supplies as needed based on program-specific workflows
• Conduct occasional hospital visits to support hospital discharge planning or participate in case conferences for complex cases
• Conducts home visits with the client following program-specific timelines to complete comprehensive assessments in partnership with the program funder, client and family to inform the development client goals within the program and an individualized client care plan
• Arranges and adjusts home care services according to the care plan and in alignment with services contained within the program bundle
• Monitors appropriate service allocation and bundle management
• Attends program huddles with internal teams, hospital partners and/or program funders
• Arranges appointments and liaise with the client’s primary care provider within set program specific timelines, supports the client to connect with primary care when required
• Completes documentation after encounters with clients and their care team and communicates any risk-related events to the VHA team in a timely manner
• Completes referrals to appropriate community services when needed and facilitates a seamless and supporting transition to these services
• Provides direct care to the client and trains staff on delegated acts as required
• Monitors program metrics and participates in program evaluation and process improvement

Key skills, experience and behaviours required for this position:

• Undergraduate degree in Nursing (RN Required)
• 5+ years of experience in home and community health or a related field
• Member, in good standing with College of Nurses of Ontario
• Knowledge of the health care delivery system including hospital discharge planning, home and community care, and support services
• Excellent skills in case management, coordinating care within interdisciplinary teams, interRAI assessments and navigation of community services
• Excellent assessment and decision-making skills
• Passion for excellent customer service and customer experience
• Effective time management skills, with the ability to work independently and co-operatively in a busy multidisciplinary environment in various settings (e.g. at the hospital, in the office, in the community).
• Proficient skills in Microsoft Office (Word, Excel, PPT) and comfort with learning/working with new and emerging technologies (e.g. EHR systems, reporting systems)
• Intersectoral experience and excellent relationship building skills and dispute resolution
• Must be available for on-call support
• A valid driver’s license and access to a reliable vehicle