Registered Nurse

The Acute Care Transitions Program ensures seamless, compassionate care as patients move from hospital to home. Designed to support both patients and their families, the program connects individuals with community-based healthcare providers, social support services, primary care and acute care teams. Together, they create personalized plans that improve outcomes and ease the transition to home.

We are seeking a dynamic and passionate Registered Nurse who wants to be part of the transformational change in home and community care by providing care in a truly client-centered approach. You are excited about working in an environment that puts the care team in the driving seat; being part of a self-directed team that offers a high level of professional autonomy and responsibility.

You will be part of a diverse care team that will provide services to a roster of clients in the community. You be part of a collaborative team that will conduct joint care planning with a focus on client-centered goals addressing client’s physical, cognitive, social, emotional, and spiritual domains, creating a holistic care plan. Each client is assigned a primary care clinician, a member of the interdisciplinary team who will lead care planning for that client and facilitate interdisciplinary team to reach client’s care goals.

As part of the SE Transitions team, you will be a part of the team that will be accountable for the care and services you provide and the outcomes your clients achieve.

Full time permanent role - guaranteed 37.5 hours a week with 12 hours shifts

• Competitive Total Rewards.So much more than a paycheque! Enjoy comprehensive benefits, pension, on-demand pay, car loan support, supportive housing and exclusive staff perks.
• Growth That Meets Your Ambition
  Build your skills with education bursaries, tuition support, ongoing training and mentorship. Our leadership team is available 24/7 to help you practice to full scope and deliver excellent care. With diverse roles and locations across Canada, you’ll have opportunities to explore new career paths or move into support and leadership positions.
• Innovative.At SE, we are always looking for new, innovative ways to improve. You’ll be encouraged and supported to identify and make improvements to the way we do our work. As a social enterprise, we support research into Senior’s Health and Aging.
• Purpose & Impact
  Join a national social enterprise where your voice matters. Every role helps advance health, spark innovation and strengthen communities across Canada.
• Manage your life. At SE, you’ll be supported with the time you need to meet the needs of your clients and meet your own needs, develop yourself and your career, and be part of a team.
• Support to be your best. At SE you are afforded the time you need to help patients, to build rapport, to accomplish patient care and recovery goals, and to understand the home and life environments that impact recovery in a way you can’t in most other settings. At SE, you meet your patients where they are, and together you take them to new heights

• Provision of comprehensive care in an interdisciplinary team
• Primary contact for a client when designated as the primary care provider/clinician for the client’s interdisciplinary team
• Provide continuous and comprehensive support to your team in the delivery of care for your client’s
• Complete a client assessment and develop an interdisciplinary care plan based on best evidence/practices and on client’s unique needs.
• Lead the care planning process and work with other disciplines to complete and implement interdisciplinary client care plans
• Facilitate regular interdisciplinary team communication (e.g. huddle, rounds, status updates) when designated as the primary care provider/clinician
• Lead discharge and transition care planning discussions during regular integrated team meetings with their front-line staff when designated as the primary care provider/clinician
• Facilitate and organize family and caregiver meetings
• Support the client through care transitions by collaborating and connecting the client with community support services in their local…