30+ days ago


At Home and Community Care Support Services Toronto Central by providing an accessible workplace, we want all of our employees to feel valued, appreciated, and free to be who they are at work. That is why we are intentionally committed to diversity and inclusion by providing an accessible and inclusive work place for all persons. We are strongly committed to include Black, Indigenous, visible minorities, Francophone, 2SLGBTQ+ persons, neurodiversity, women, national origin, ancestry, disability status, age, marital status, pregnancy, citizenship, all faiths, or any other aspect, which makes them unique, through recognizing each applicant through anti-racism and anti-oppressive practices to ensure equitable opportunity.


The Telehomecare Nurse will provide remote client monitoring, health coaching, and disease-specific education to clients with complex chronic diseases, including Chronic Obstructive Pulmonary Disease and Heart Failure. Working in collaboration with the client’s circle of care, the Telehomecare Nurse will focus on enabling the client to better manage his/her chronic disease through the support of monitoring and coaching. In addition, the Telehomecare Nurse will undertake comprehensive assessments of client needs, develop the service plan, and connect the client with other community resources as required.

Responsibilities include;

  • Obtaining informed client consent to participate in the Telehomecare Program
  • Collaborating with clients, families/care givers, service providers and other health care partners to complete comprehensive assessments and identify client needs
  • Developing, coordinating, monitoring and evaluating comprehensive service plans designed to meet client centred goals
  • Assisting clients in establishing chronic disease self-management goals, by coaching and monitoring through alert management using established clinical protocols and guidelines
  • Delivering client education using validated educational tools and resources and conducting regular health coaching sessions with clients
  • Monitoring and coaching a minimum of 60 clients remotely
  • Collaborating with Home and Community Care Coordinator, caregiver, hospital, interdisciplinary team, Primary Care Provider and other providers as required
  • Negotiating and advocating for clients as appropriate
  • Other duties as required                                                                                                      


  • Registered Nurse in good standing with the College of Nurses of Ontario.
  • A minimum of two (2) years relevant clinical and community health experience.
  • Demonstrates strong knowledge base and previous experience working with patients with complex chronic diseases (e.g. CHF, COPD, and Diabetes).
  • Demonstrates knowledge of adult education, health coaching, patient self management and case management principles.
  • Demonstrates excellent interpersonal skills and ability to foster collaborative relationships, clients/ families and or community partners.
  • Demonstrates ability to work collaboratively with other professions/ disciplines in a team environment.
  • Demonstrates the ability to communicate effectively with clients and/or their families to ensure accurate and seamless information is conveyed and documented.
  • Demonstrates evidence of excellent problem solving, organizational, communication and critical thinking and listening skills.
  • Demonstrated ability to use technology and best practices to remotely monitor patients.
  • Ability to multi-task and work in a fast paced environment.
  • Safeguards confidentiality of verbal, written and electronic client information.
  • Knowledge of Home and Community Care Support Services priorities, policies, practices and service standards.
  • French language is an asset.
  • Ability to speak an additional language is an asset.
  • Basic proficiency with computerized information systems.
  • Must have a valid driver’s license and access to a vehicle.