Transitions Care Lead

About the Role

An exciting leadership role within hospital transitional programs working closely with hospitals to transition and reintegrate clients back into the community.

As a member of the Acute Transitions leadership team, you are passionate about informing and shaping the transition from hospital to home and being at the forefront of healthcare innovation in Canada.

As the Transitions Care Lead, you will provide exemplary leadership and care flow management between the hospital partners and community care teams while ensuring excellence in the provision of client care and the achievement of corporate/program objectives. This exciting position will manage relations and collaborate with hospitals to ensure a smooth and seamless transition to a client’s home environment. Additionally, this position will help to ensure performance targets are met and be involved in quality improvement initiatives as it relates to optimizing patient flow and management processes within the Acute Transition programs.

Full time role - Remote opportunity

Main responsibilities:

1. Act as the primary point of contact for the hospital navigator/coordinator
2. Receive, monitor and update the client tracking/notification/flow tools
3. Receive, review, and accept referrals for in-home transition services
4. Coordinate/Liaise with hospital navigator/coordinator and SE @home Team as required
5. Participate in hospital discharge care conference for complex clients as required
6. Prepare an initial care plan (e.g. for 48-72 hours post transition) and place an initial equipment and supplies order as required
7. Ensure all necessary referral documents (e.g. transition request form, medical orders, consult notes, allied health reports) and initial care plan instructions are received by SE @Home Team
8. Attend program huddles with hospital (as per contract requirements)
9. Monitor and communicate significant deviations from the care plan to the hospital as required
10. Communicate to the hospital any risk-related events
11. Monitor timely completion and reporting outcomes of patient/family care conferences to partner hospital (required in contract)
12. Monitor Program Metrics (e.g. client experience, time to first visit, service volumes, risk events, etc.)
13. Facilitate risk management as per established policies and procedures
14. Communicate patient and family complaints or issues back to partner hospital and share associated action plans in partner meetings
15. Participate in program evaluation and process improvement
16. On-call as required for program support
17. Other duties to ensure program is running smoothly

Requirements:

1. Membership, in good standing, with the applicable regulatory body:
2. College of Nurses of Ontario
3. College of Physiotherapists of Ontario
4. College of Occupational Therapists of Ontario
5. Ontario College of Social Workers and Social Service Workers
6. 3+ years of recent experience in community health or a related field
7. Knowledge of the health care delivery system including hospital discharge planning, community care and support services
8. Excellent skills in case management and coordinating care within interdisciplinary teams
9. Excellent assessment and decision-making skills
10. Passion for excellent customer service and customer experience
11. Demonstrates strong critical thinking, problem-solving and self-directed skills
12. Excellent interpersonal communication and presentation skills with a diverse group of stakeholders (hospital partners, front line staff, management team)
13. Effective time management skills, with the ability to work independently and co-operatively in a busy multidisciplinary environment in various settings (e.g. at the hospital, in the office, in the community)
14. Advanced skills in Microsoft Office (Word, Excel, PPT, Visio) and comfort with learning/working with new and emerging technologies (e.g. remote patient monitoring/virtual care technologies, EHR systems, reporting systems)
15. A valid driver’s license and access to a reliable vehicle

About Us:

At SE, we love what we do. Every day, we bring hope and happiness to clients, homes, and communities across Canada. We treat each person with dignity and love, like our own family; we build empathy; and we do the right thing. We are always inspired to make a difference. As a not-for-profit social enterprise, we share knowledge, provide the best care, and help each client to realize their most meaningful goals for health and wellbeing. We are an inclusive workplace offering competitive pay, benefits, pension, and work-life balance. We’re a great place to work, and we hope you’ll join our team.

In the interest of the health and safety of our patients/clients, employees, and greater good of public health, SE Health requires those that wish to work for this organization to be fully vaccinated against COVID-19. Fully vaccinated means a person has received both doses of the COVID-19 vaccine and it has been 14 days since the last dose.

SE Health is committed to the success of all its employees. If you feel you need accommodations because of illness or disability, please do not hesitate to contact the Talent Acquisition team at careers@sehc.com at your earliest convenience.