Reporting to the Senior Director, Quality and Integrated Care the Registered Nurse of Integrated Care works within a multi-disciplinary team, determines client eligibility for services, and develops individual care and service plans.



1. Overseeing and Managing High Intensity Support at Home (HISH) Program

  • Oversees the operations of HISH Program by providing comprehensive nursing care to clients to enable them to achieve optimum health and quality of life
  • Provides skilled nursing services in accordance with the client care plan and primary care physician’s order
  • Supervises HISH Program Team by monitoring and coordinating the overall day-to-day quality of care and clients’ safety. Duties are as follows but not limited to:
  • Monitoring the clients’ vital signs including pain management
  • Monitoring blood glucose levels as necessary and providing health teaching and support for clients and family
  • Medication administration, monitoring and support
  • Wound assessment, dressing changes and assessment of the healing process
  • Monitoring and care of I.V. therapy, PICC lines, catheters and ostomy
  • Reports concerns and/or changes in clients health to Primary Care Physician (PCP), HISH Team and circle of care
  • Supervision of CANES and subcontractor PSWs when required
  • Regular  health teaching and support to clients and family, explaining their roles and providing education materials as necessary
  • Responsible for emergency preparedness plan of the program and implements it in times of emergency
  • Complies with organization and legal requirements by observing nursing practices that adhere to the organization’s vision, mission and core values
  • Utilizes Infection Prevention and Control best practices by following policies and procedures to prevent the spread of infection
  • Ensures the fair and equitable treatment of all HISH Team
  • Attends internal and external meetings, trainings, conferences and health fairs
  • Demonstrates a positive professional attitude when representing CANES Community Care

2. Client Assessments

  • Conducts initial and ongoing in-person or virtual client assessments in collaboration with client, family, and circle of care according to the Organization’s guidelines
  • Evaluates client and family’s responses to care plan for achievement of realistic client-centred outcome and advises circle of care as required
  • Respects client’s choices and decisions
  • Coordinates client care needs by reporting and discussing client’s health status on a regular basis with other members of the circle of care including the PCP
  • Contributes to a culture of client safety and employee Health and Safety, by complying with all safety practices of the organization, reporting unsafe practices and adverse events, and acting on safety recommendations
  • Conducts Delegated Acts Trainings and health teachings to unregulated and regulated health care providers, clients, family members and PSWs with the scope of nursing practice as required

3. Data Management and Reporting

  • Maintains accurate documentation and reporting in relation to client care
  • Processes referrals as necessary and update statistical reports regularly
  • Ensures accuracy, confidentiality and safekeeping of clients and organization’s records
  • Performs other duties as assigned



  • Diploma in Nursing
  • Registered Nurse (RN) designation required
  • Must be registered with the College of Nurses of Ontario
  • Ability to work independently and remotely with minimal supervision
  • Ability to work with diverse communities
  • Excellent oral and written communication, assessment and problem solving skills
  • Knowledge of computer programs i.e. interRAI Community Health Assessment Tool, Screener, Procura, Word, Excel, etc.
  • Valid class G driver’s license and access to reliable vehicle with valid insurance
  • Knowledge of OH&S Act and Regulations
  • Clear Police Reference Check with Vulnerable Sector Screening

We thank all applicants for their interest, however, only those selected for an interview will be contacted.

CANES Community Care is an Equal Opportunity Employer

CANES is committed to making employment opportunities accessible in accordance with the Accessibility for Ontarians with Disabilities Act, 2005. Upon request, accommodation will be provided in all parts of the application and hiring process.

Contract length: 6 months

Application deadline: 2021-01-08