Provides the first in-home nursing visit within twenty-four (24) hours of hospital discharge for patients with complex/chronic diseases including CHF, COPD, Diabetes or other; Completes a clinical, problem-based head to toe assessment; Confirms the patient’s hospital discharge plan; Performs medication reconciliation for patient and reviews medication protocol with patient and caregiver; Utilizes a "teach back" approach to help the patient and family understand the care plan, treatments, symptom management, and when/who to ask for help; Initiates communication with the patient's primary care provider, and ensures follow up with primary care within seven (7) days; Refers to longer-term community programs through the Care Coordinator as required, once goals of Rapid Response program are met. Preference will be given to experience within the last 2-3 years; Certificate in Geriatric Nursing (GNC) or Certified Nurse in Critical Care Pediatrics (CNCCP) an asset; Superior clinical assessment skills; Ability to provide quality clinical service delivery in conjunction with patients and other stakeholders; Ability to work independently; Strong critical thinking and problem solving skills; Effective interpersonal and communications skills; Ability to provide health coaching and disease-specific education to patients; Advanced oral and written proficiency in English and French is essential; Must have valid driver’s license and access to a vehicle, as travel to patient homes will be required; Valid CPR Certification.