Home Care Specialist (1-Year Contract)

Veterans Health Administration•Toronto, ON

1d•CA$61,000 - CA$76,000•Hybrid

About The Position

VHA Home HealthCare (VHA) is seeking a Home Care Specialist, a 1-year contract position, for Registered Nurses (RNs). This role involves providing care coordination, case management, and system navigation services to clients in various integrated care programs, including Hospital@Home, Hospital to Home, and OHT-lead programs. The Home Care Specialist will support clients transitioning from hospital to home and provide ongoing case management. This position acts as a liaison between clients, hospital partners, primary care, and community care teams to ensure continuity of care and alignment with program objectives. Collaboration with program funders is essential for smooth, client-centered transitions and quality improvement efforts aimed at optimizing patient flow, care coordination, and service delivery.

Requirements

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

Responsibilities

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