Job Description

We are looking for: A Full-Time, Permanent Visiting Nurse

Hours of Work:

Monday - Friday 8:30AM - 4:30PM. Requirement to be part of weekend and holiday rotation.

Location:

This role requires travelling in the community. Generally within central and west Toronto.

Reports to:

Manager, Hospital to Home and Clinical Programs

Compensation & Benefits

Salary Range:

The salary for this role ranges from $65,000 to $88,000 per year, depending on your skills and experience.

On top of a competitive base salary, we support rest and overall wellness through generous paid time off for vacation, personal and sick days.

Circle of Care Perks:

Health and Dental Benefits:

A robust benefits plan with comprehensive health, dental, paramedical and vision coverage with employer paid premiums to support you and your family through all stages of life.

Retirement Savings Plan:

As part of our commitment to your long-term well-being, we provide an RRSP program through RBC with employer and voluntary employee contributions.

Learning and Development:

We support your continued growth and learning through paid training and professional developmentopportunities throughout your career.

Responsibilities

Nursing

- Establish trust and respect with patients/family to understand their goals and preferences for care.
- Facilitate a smooth transition from hospital to home by providing supportive, non-judgmental care and guidance throughout the process.
- Review the Patient Service Plan, plus the Referral Information Package for the reason for hospitalization, surgical procedures, past medical history, list of diagnoses, reportable signs and symptoms, medical orders for nursing, follow-up appointments,



and list of discharge medication.
- Conduct comprehensive assessments of patient needs and connect them with primary care providers and relevant services such as PT, OT, PSS, SW, RD, SLP.
- Accept patient referrals from the hospital, clarify any questions with the Manager, and liaise with hospital care team as needed to identify barriers to care
- Collaborate with patients to overcome transition challenges, ensuring they receive the appropriate support for their well-being.
- Deliver supportive health education, including chronic disease self-management strategies, to patients dealing with complex or chronic health conditions.
- Maintain accurate, timely, and thorough professional documentation of patient interactions, care plans, and progress as per CNO standards and Circle of Care policies.
- Initiate transition planning throughout service and work closely with community partners, such as Ontario Health at Home for a warm handoff.
- Promote needs-based, ethical practices, and health equity in recommending professional services and social prescribing for patients.
- Review the supply inventory available in the patient's home and report any gaps or needs to the Manager to ensure adequate supplies are available for ongoing treatment.

Conduct In-Home Client Assessments

- Complete in person community visits at patients' home.




- Provide ongoing assessment/reassessment of patients' and their need for service according to program and organizational guidelines.
- Develop care plans based upon patient involvement to optimize their health and functional status.
- Complete medication reconciliation on admission and discharge.
- Complete InterRAI-HC tool for each patient prior to their discharge from the program.
- Ensure all necessary documentation is completed and required consents are obtained. Return all healthcare records to the office following the patient's discharge from the hospital, following the Records Management return process.
- Submit Professional Service Reports within three days of the initial visit and submit Transition/Discharge Reports as requested or within 7 days of discharge.
- Perform treatment-based interventions as required, including but not limited to: IV therapy, wound care, catheterization, and medication administration. All interventions must fall within the scope of nursing practice and be based on physician orders.
- Advocate on behalf of the patient to ensure their needs are met.
- Complete initial and follow-up goal achievement, with patient/caregiver input.
- Participate in case conferences and huddles.
- Maintain regular contact with Manager and Service Coordinators.
- Use motivational interviewing with patients and families and engage patients and families in partnership using empathy to manage frustration and escalation.
- Provide after-hours support to patients and their families as needed.

Monitor/Training Personal Support Workers

- Carry out delegation or shadow visits for Personal Support Worker

📌 Visiting Nurse (Toronto)
🏢 Colonial Group
📍 Toronto