We are looking for Clinical Nurse Specialists to join our Nurse Led Outreach Team!

The Clinical Nurse Specialist (CNS) for the Nurse Led Outreach Team (NLOT) program is primarily responsible for supporting direct and specialized clinical care to residents living in Long-Term Care (LTC) homes, within a specific sub-regional boundary. The CNS works in collaboration and consultation with physicians, navigators, coordinators, and other members of the inter-professional health care team to prevent avoidable ED visits and hospitalizations, and to support transitions to and from hospital, when needed. The CNS will act as a link between the hospital and the LTC homes to ensure the most appropriate and efficient clinical care provision.

The CNS will also support NLOT program development, that is agile and iterative, reflective of the energetic nature of resident care need as well as evolving Ontario Health and Ministry of Long-Term Care priorities.

In collaboration with the Clinical Team Manager and Nurse Practitioners, you will be responsible for supporting and being part of a high-performance team, ensuring the delivery of quality and safe care for patients and families. Educate health care team members in best practice standards as it relates to the management of complex and frail geriatric patients. The CNS will contribute to program development, research, and academic development of future health care professionals, in order to promote the integrated care model.

Duties and Responsibilities: The CNS works within 4 domains of practice.

Clinical Domain

- Serves as an expert nursing clinical resource in the field of geriatrics to patients, families, nursing colleagues and other health care professionals for enhancement of patient care and nursing practice. On a practical level, you will
- Assist in avoiding hospital admissions for current LTC residents who have new, or increasingly complex medical or specialized equipment needs which cannot currently be accommodated in their LTC home
- Support placement of eligible high needs designated Alternate Level of Care (ALC) patients from hospitals into LTC
- Enable the admission of community members with specialized needs to LTC homes
- Assume a leadership role in influencing clinical practice and patient outcomes.
- Assist in reducing non-urgent transfers to the region’s Emergency Departments
- Provide capacity building for LTC staff to develop and enhance competency for acute treatment protocols
- Where clinical need exceeds LTCH staff knowledge and/or capacity,



support direct clinical intervention, monitoring and follow-up for acute and chronic needs

Knowledge Translation
- Promotes best practices for seniors care supporting practice and environmental changes to support care
- Critically appraises geriatric related research and applying it to practice, quality and patient safety initiatives
- Builds nursing capacity by supporting implementation and evaluation of evidence based practice at the point of care
- Provide leadership and promote excellence in patient-centred nursing care through expert practice, education, consultation and research
- Actively participate in a Regional NLOT Community of Practice
- Provide input and support in the development and implementation of integrated hospital-community-LTCH clinical pathways
- Develop linkages with external partners as appropriate to ensure continuity of care
- Integrates research into practice to ensure best practice standards are maintained, and opportunity for new nursing knowledge.
- Map present and future trends to create and sustain a seamless and continuous process for LTC residents
- Assumes a leadership role in influencing clinical practice and patient outcomes and collaborates with the broader health care team and community partners regarding complex and challenging patient care situations

Scholarship
- Identifies changing trends in population health and collaborates with the team and regional partners to adapt practice to changing needs
- Leads nursing research activities and quality improvement initiatives, incorporating patient satisfaction data
- Mentors nurses in the development of abstracts, presentations and publications
- Identifies opportunities to engage with research teams as co-investigators
- Participates in presentations/publications of research and quality improvement initiatives
- Eligible for cross appointments with affiliated/approved institutions to build coalitions, share resources, knowledge and expertise

Leadership
- Facilitates and actively promotes decreasing avoidable ED transfers or hospital admissions and LOS for LTCH residents




- Facilitates and participates in developing education / training, guidelines and other practice documents to support LTCH clinical staff
- Supports identification of opportunities for collaboration with academic and health care partners

Qualifications

- Must have Current General Class (Practicing) Registration with the College of Nurses of Ontario.
- Master of Nursing degree required.
- Current BLS certification
- A minimum of 3 years’ experience working as a Registered Nurse in Acute Care or Long-Term Care settings is preferred

- CNA Certification in Gerontology preferred
- Gentle Persuasive Approach Certification preferred
- Current or recent experience as an educator preferred.
- Expert clinical skills in the assessment, planning, implementing, evaluating, and documenting of the delivery and coordination of care for LTC residents and their families.
- Excellent communication and interpersonal skills including negotiation skills.
- Excellent leadership, collaboration, decision making, problem recognition and problem-solving skills.
- Excellent change management, organizational and analytical skills.
- Excellent project management skills
- Computer-based literacy in word processing and database management
- Working knowledge of the College of Nurses of Ontario standards of practice
- Demonstrated and ongoing commitment to continuing professional development.
- Evidence of program design & development, and resources development skills
- High level of initiative works independently and able to effectively lead to achieve outcomes.
- Demonstrated knowledge of evaluation methodologies. Support and participate in ongoing program development and quality improvement initiatives.
- Effective patient/family counseling skills
- Must have an excellent attendance record.

Travel Is Required

Unity Health Toronto is committed to creating an accessible and inclusive organization. We strive to provide a recruitment process that is barrier-free and in compliance with the Accessibility for Ontarians with Disabilities Act (AODA) and the Ontario Human Rights Code. We understand that you may require an accommodation at any stage of the recruitment process.

When you are contacted, please inform the Talent Acquisition Specialist and we will work with you to meet your accommodation needs. We want to emphasize that all accommodation requests are handled with the utmost confidentiality, respecting your privacy and dignity.

📌 Clinical Nurse Specialist NLOT (Toronto)
🏢 St. Joseph's Health Centre, Toronto
📍 Toronto