Registered Nurse – Home-Based Transition Care Program (HBTCP)

The Northumberland Family Health Team (NFHT) is seeking a dynamic and compassionate Registered Nurse (RN) to join our innovative Home-Based Transition Care Program (HBTCP) on a permanent part-time basis (0.4 FTE, 2 days/wk).

The successful candidate will bring strong clinical assessment and critical thinking skills, particularly in the areas of Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), and chronic disease management. This role requires the ability to provide patient-centered education that supports improved health outcomes and empowers patients to effectively self-manage their conditions and symptoms.

Working collaboratively with a Nurse Practitioner and family physicians, the RN will provide home-based care to patients transitioning from hospital to home or those at risk of hospital admission or Emergency Department visits. The RN will use evidence-based clinical practices to assess, monitor, develop, and implement individualized care plans focused on symptom stabilization, patient and caregiver education, and prevention of hospital readmission.

Services begin prior to hospital discharge and continue for approximately 4–8 weeks, concluding with a transition back to the patient’s primary care team.

About NFHT

NFHT is a non-profit primary health care organization serving more than 26,000 patients through a comprehensive range of programs and services focused on disease prevention, chronic disease management, and improved health outcomes. Our interprofessional team includes family physicians, nurses, nurse practitioners, occupational and physical therapists, dietitians, social workers, and pharmacist working together to provide collaborative, person-centered, and integrated care. To learn more about the NFHT, visit:
www.nfht.ca.

NFHT is committed to fostering a diverse, equitable, inclusive, and accessible workplace free from harassment and discrimination. We welcome applications from all qualified candidates, including women, visible minorities, Indigenous peoples, persons with disabilities, and individuals from diverse backgrounds.

Accommodation is available throughout the recruitment process in accordance with the Accessibility for Ontarians with Disabilities Act (AODA). Applicants requiring accommodation are encouraged to notify us so appropriate arrangements can be made.

Qualifications, Skills & Experience

• Bachelor of Science in Nursing (BScN)
• Current registration with the College of Nurses of Ontario (CNO), and carrying Professional Liability Insurance
• Valid Ontario Driver’s Licence, reliable vehicle, and proof of insurance
• Demonstrated ability to apply evidence-based practices in the assessment, planning, education, and care of patients with COPD and CHF
• Strong communication and relationship-building skills with patients, families, and healthcare providers
• Ability to work independently, prioritize effectively, and adapt within a flexible community-based environment
• Excellent knowledge of available community resources an asset
• Experience in Advanced Care Planning an asset

We can offer you:

• A team environment that strives for professionalism, respect and compassion, respects the role of each Interprofessional Healthcare Provider and supports all providers to work to their full scope of practice
• A flexible schedule and environment that supports work-life balance
• Paid vacation, personal leave days and professional development paid time and expense coverage
• An opportunity to enroll in and contribute to your Healthcare of Ontario Pension Plan (HOOPP)

Application Information

Interested candidates are invited to submit a resume to the attention of Theo Barker, Executive Director at: info@nfht.ca. We thank all applicants for their interest; however, only those selected for an interview will be contacted.