The Centre for Family Medicine is currently seeking a REGISTERED PRACTICAL NURSE (RPN) to join the KW4 Community Ward In-Home Team for 4-5 days per week. This is to cover a 12-18 month maternity leave.
The KW4 Community Ward-In Home (CWT) is an inter-professional team that delivers in-home primary care to complex patients in the Kitchener-Waterloo-Wellesley-Wilmot-Woolwich (KW4) area, including those who:
have complex chronic conditions
are living with mental health, psychosocial and/or addictions challenges
are very frail or have frequent falls
are not managing well, or are not getting the care and support they need
are visiting the ER or being hospitalized frequently
cannot get to regular office appointments for whatever reason
Our team currently consists of part-time nurse practitioner, two full-time outreach workers, a social worker, a chiropractor/mobility specialist, a pharmacist, a consulting physician and a team assistant.
Position Overview
The RPN is a key clinical position on the team whose role is to provide preventative and supportive care for patients in their homes, with a strong emphasis on social determinants of health. The RPN operates within their full scope of practice and as directed; and requires initiative and passion in caring for our patient population. They work closely with the whole team, and specifically assist our Nurse Practitioner. There is potential for clinic work also.
Additional Responsibilities
Team Participation
Works as both a lead and support to other Team members working with specific patients
Required to directly report back and update NP on client’s clinical needs.
Participates in discussions, gap-analyses, problem solving, and decision-making at weekly Team
meetings
Ensures that the Team and other stakeholders are kept informed about clinical developments and new and existing patient challenges as necessary
Consults with other Team members who have different or enhanced areas of expertise
Patient Care
Ability to triage, strong med-surgical skills, and excellence in at least one chronic disease (example diabetes, COPD or wound care)
Listens to patients to identify their social, physical and emotional needs in order to develop patient specific goals
Builds on existing resources and connects patients to additional resources to create a support network
Advocates for services as necessary
Negotiates with other care providers about how service is provided to ensure patient participation in their own care
Follows all safety protocols while working with residents in their home/community and clinic
Documentation and Records Management
Participates in the development of care plans (CPs)
Documents and maintains clear records in an EMR of each patient visit including supports, services and gaps
Provides clear and timely communication with other healthcare and social service providers
Other correspondence as required
Qualifications and Experience:
Current CNO Certificate as RPN
Updated CPR certification
Demonstrated ability to work independently within the RPN scope of practice
3 years of experience in healthcare, preferably working with complex patients
Experience working directly with people from diverse, racial, ethnic and socioeconomic backgrounds.
Preferred experience or education in primary health care and an adult specialty
Ability to triage, strong med-surgical skills, and excellence in at least one chronic disease (example Diabetes, COPD, or wound care)
Demonstrated ability to work collaboratively with other Allied Health Professionals
Demonstrated excellence in clinical judgment, health assessment and therapeutic skills
Demonstrated experience in social determinants of health
Proven relationship building and problem-solving skills
Proven ability to keep confidential information regarding patients, health care providers, employees,
business operations and team information
Demonstrated ability to listen effectively and to build working relationships with patients, families, care partners and other team members
Access to a reliable vehicle and a valid Ontario driver’s license are required
Experience and/or certification in mental health, geriatrics, addictions, and/or counselling are all assets
Closes: May 30, 2025
