The Community and Population Health Services (CPHS) portfolio supports the advancement of integrated health and
social services in hospital and into the community. The Program is responsible for the development and advancement of
innovative partnerships with peer, community, academic partners and provides expert leadership in the area of pre- and
post-acute care transitions.
The CPHS portfolio is accountable for HHS' Population Health, Bundled Care and Alternate Level of Care strategies.
The portfolio provides system-wide support through the Site Administrative Managers, Transitional Care & Discharge
Specialists, ALC Navigators, Centralized Care and Transition Team, Hospital to Home, Integrated Comprehensive Care
Program, and Inpatient Medical Psychiatry Consultation Liaison Teams.
Additionally, the portfolio has accountability for the Alternate Health Facility beds at the Satellite Health Facility and St.
Joseph's Villa, and Addictions Services at the Hamilton Sites.
The McMaster Family Health Team (McMaster Family Practice, Stonechurch Family Health Centre and Canadian Blood
Services) and Behavioural Supports Ontario (BSO) are aligned to the portfolio.

Hamilton Health Sciences fosters a culture of patient and staff safety, whereby all employees are guided by our Mission, Vision, Values, and Values Based Code of Conduct. Hamilton Health Sciences is a teaching hospital and all staff and physicians are expected to support students and other learners.

To be considered for this opportunity applicants must apply during the posting period. All internal and external applicants may ONLY apply via the Careers website.

Hamilton Health Sciences is an equal opportunity employer and we will accommodate any needs under the Canadian Charter of Rights and Freedom, Accessibility for Ontarians with Disabilities Act and the Ontario Human Rights Code. Hiring processes will be modified to remove barriers to accommodate those with disabilities, if requested. Should any applicant require accommodation through the application processes, please contact HR Operations at 905-521-2100, Ext. 46947for assistance. If the applicant requires a specific accommodation because of a disability during an interview, the applicant will need to advise the hiring manager when scheduling the interview and the appropriate accommodations can be made.

This competition is open to all qualified applicants, however, qualified internal applicants will be considered first. Past performance will be considered as part of the selection process. If you are a previous employee of Hamilton Health Sciences, please note: the circumstances around an employee's exit will be considered prior to an offer of employment

Proficiency in both Official Languages, French and English, is considered an asset

If this position is temporary, selection for this position will be as per the outlined Collective Agreements:

Article 30 (k), CUPE Collective Agreement

Article 10.7 (d), ONA Collective Agreement

Article 13.01 (b) (ii), OPSEU 273 Collective Agreement

Article 14.04, OPSEU 209 Collective Agreement

Article 2.07 and Article 13, PIPSC RT Collective Agreement

1. Registered Nurse in good standing with the College of Nurses of Ontario;
2. Competent to perform CPR at a Basic Cardiac Life Support level;
3. 3 to 5 years demonstrated expertise working with general internal medicine patients with multi-morbidity and frailty
required;
4. Demonstrated knowledge of comprehensive geriatric assessment and interventions required;
5. Demonstrated knowledge and application of Assess & Restore Philosophy of Care required;
6. Demonstrated expertise and competence in case management and discharge planning, required;
7. Recent 3 to 5 years demonstrated comprehensive knowledge of community resources and health care delivery
systems in acute, primary care and community settings, required;
8. Recent 3 to 5 years of demonstrated expertise and competence in assessment and interventions related to health
literacy and social determinants of health required;
9. Demonstrated ability to respond to patients and situations with flexibility and adaptability;
10. Excellent interpersonal, communication, organization, teaching and decision-making skills required;
11. Demonstrated leadership skills, including problem solving, critical thinking, conflict resolution and negotiation
required;
12. Demonstrated ability to work independently and interdependently with interdisciplinary teams, primary care, and
community services required;
13. Demonstrated knowledge in quality improvement preferred;
14. Excellent time management and stress management skills required;
15. Fluency in English and demonstrated excellence in oral and written communication;
16. Computer literacy and basic proficiency required.
As a condition of employment, you are required to submit proof of full COVID-19 vaccination to Employee Health
Services.

Working with the Centralized Care and Transition Team (CCaTT) the Nurse will be registered with the College of Nurses
of Ontario working within the scope of practice of a Registered Nurse (RN). The RN utilizing a patient and family centered
model of care will be responsible for developing and advancing best practice and care plans for patients with multimorbidity
who are often frail, impacted by social determinants of health and may not be health literate. The RN will work
collaboratively with interdisciplinary teams applying the Assess & Restore Philosophy of Care to develop integrated
transition plans with community partners with goal of optimizing outcomes for at-risk patients. The RN will be involved
with high-risk patients in the ED who do not require admission, and admitted patients. Additionally, the RN will assist
community partners such as Long Term Care to navigate the hospital system ensuring time access, and thereby
supporting care in the community where appropriate.

Monday- Friday; Days, weekends, Holidays (Extended Tours)