INTRODUCTION:
As part of the Primary Care Team, the Registered Nurse (RN) Outreach is an integral member of DAHC’s interdisciplinary care team, providing wholistic, culturally safe, trauma-informed, and patient-centred care to Indigenous individuals and families in Brantford and surrounding area. The RN Outreach role combines primary care nursing, chronic disease management, outreach, and care coordination. Working as part of an interdisciplinary team, the RN Outreach supports patients across the lifespan through assessment, triage, preventative care, chronic disease follow-up, diabetes education, outreach services, and referrals.
This role supports DAHC’s satellite clinic services, outreach initiatives, and collaborative community partnerships to improve access, continuity, and coordination of care.
REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:
· Provide nursing assessments, triage, health screening, care planning, and follow-up care
· Respond to patient calls, same-day appointment requests, EMR messages, and provider-directed patient care tasks
· Complete blood work, monitor results, and communicate findings to patients
· Administer immunizations, injections, preventative care interventions, and nursing treatments
· Provide nursing care under approved medical directives and/or primary care provider orders.
· Support chronic disease management, diabetes education, preventative care, and patient self-management
· Develop, implement, monitor, and evaluate individualized care plans in collaboration with the interdisciplinary team
· Provide patient education related to diabetes, chronic disease prevention, healthy living, wellness, and preventative care
· Support outreach and satellite clinic services, including community-based nursing visits
· Facilitate referrals, care coordination, case management, and continuity-of-care planning
· Support patients experiencing barriers to care, including unhoused individuals, transportation challenges, chronic disease complexity, mental health and addictions concerns, and limited access to primary care
· Participate in team huddles, case conferences, clinical meetings, program planning, and quality improvement activities
· Maintain accurate, timely, and confidential documentation within the EMR
· Support clinic operations, infection prevention and control, and safe clinical practices
· Build collaborative relationships with Indigenous organizations, community partners, health system partners, and the patient’s circle of care
· Provide all care from a culturally safe, patient-centred, and trauma-informed approach
· Strong interprofessional communication and collaboration skills
STATEMENT OF QUALIFICATIONS:
· Bachelor of Science in Nursing or equivalent nursing degree
· Current registration in good standing with the College of Nurses of Ontario
· Certified Diabetes Educator designation, or willingness to work towards certification within an agreed-upon timeframe
· Minimum 3 to 5 of nursing experience; experience in primary care nursing in various community and/or outreach settings;
· Knowledgeable in areas of chronic disease management and education, community health, outreach, emergency care, and Indigenous health is considered an asset
· Current Basic Cardiac Life Support certification
· Proof of professional liability insurance
· Strong assessment, triage, clinical decision-making, and critical thinking skills
· Strong interpersonal, communication, teaching, counselling, and documentation skills
· Knowledge of Indigenous health, health equity, social determinants of health, and barriers to care
· Experience supporting patients with chronic illness, mental health and addictions concerns, harm reduction, family-centred care, and/or complex social needs is considered an asset
· Strong computer and electronic medical record skills
· Valid driver’s licence and access to a reliable vehicle
· Ability to work across DAHC Brantford Clinic, outreach locations, satellite clinics, and partner sites as required
· Experience working with Indigenous communities is considered an asset
· Knowledge of local Indigenous organizations, programs, and services is considered an asset
Pay: $75,000.00 per year
Benefits:
- Company pension
- Dental care
- Employee assistance program
- Extended health care
- Life insurance
- On-site parking
- Paid time off
- Vision care
Flexible language requirement:
Education:
- Bachelor's Degree (preferred)
Experience:
- nursing experience in a primary care, community health: 3 years (required)
Licence/Certification:
- Certified Diabetes Educator (required)
- certificate of registration from CNO (required)
Work Location: In person
