Locations: Amherstview, ON
The Transitional Care Unit supports individuals who are medically stable but require additional short-term care, monitoring, rehabilitation, or discharge planning before safely returning home or transitioning to another care environment. Residents may be admitted following hospitalization, surgery, illness, injury, or a significant change in their health or functional status.
This position is ideal for Nurse Practitioners who enjoy working autonomously, managing complex clinical needs, and collaborating with interdisciplinary teams to help residents achieve the best possible health and functional outcomes.
Key Responsibilities
- Provide comprehensive primary and advanced nursing care to residents admitted to the Transitional Care Units.
- Complete initial and ongoing health assessments, including physical examinations and clinical evaluations.
- Diagnose acute and chronic health conditions within the Nurse Practitioner's scope of practice.
- Develop, implement, and regularly review individualized treatment and transitional care plans.
- Prescribe medications, treatments, diagnostic testing, and therapeutic interventions as appropriate.
- Monitor residents following hospital discharge, surgery, illness, or changes in medical condition.
- Manage chronic conditions, acute health concerns, pain, infections, wounds, medication-related issues, and other complex clinical needs.
- Identify changes in resident condition and provide timely clinical intervention to reduce avoidable emergency department visits and hospital readmissions.
- Support medication reconciliation and continuity of care following hospital discharge.
- Collaborate with physicians, nursing staff, pharmacists, physiotherapists, occupational therapists, social workers, dietitians, and other members of the interdisciplinary care team.
- Communicate with residents and families regarding diagnoses, treatment options, progress, goals of care, and discharge planning.
- Participate in care conferences and provide clinical recommendations related to resident care and transition planning.
- Support safe and timely discharge by identifying medical, functional, and social barriers that may affect a resident's transition.
- Provide education and clinical guidance to nursing staff, residents, and family members.
- Maintain timely, accurate, and comprehensive clinical documentation in accordance with College of Nurses of Ontario requirements and organizational standards.
- Participate in quality improvement initiatives focused on resident outcomes, patient safety, hospital diversion, and continuity of care.
- Follow all infection prevention and control, privacy, workplace safety, and organizational policies.
Qualifications
Candidates must possess:
- Current registration as a Nurse Practitioner with the College of Nurses of Ontario, in good standing.
- Authorization to prescribe medications and perform controlled acts within the Nurse Practitioner's scope of practice.
- Previous experience in long-term care, transitional care, primary care, geriatrics, hospital medicine, rehabilitation, or complex continuing care is strongly preferred.
- Strong clinical assessment, diagnostic, treatment planning, and decision-making skills.
- Ability to work independently while collaborating effectively with an interdisciplinary healthcare team.
- Excellent communication, documentation, organization, and time-management skills.
- A resident-centred and compassionate approach to care.
- Ability and willingness to travel between the Fordwich and Exeter locations.
Required Documentation
Successful candidates must provide:
- Current Ontario Nurse Practitioner licence in good standing.
- Vulnerable Sector Check completed within the last six months.
- Two-Step TB Test completed within the last six months.
- Proof of required COVID-19 vaccination.
- Current seasonal influenza vaccination.
- Current CPR and First Aid certification.
- Current mask-fit testing documentation.
- Any additional documentation required by the facilities or applicable legislation.
What We Offer
- Competitive hourly rate
- Flexible scheduling, with on-site days arranged in advance.
- Opportunity to work across two supportive Transitional Care Unit environments.
- A collaborative interdisciplinary team and strong clinical support.
- Professional autonomy within the Nurse Practitioner's scope of practice.
- The opportunity to support hospital-to-community transitions and reduce preventable hospital readmissions.
- Meaningful work that directly contributes to resident recovery, independence, and quality of life.
