About the Role
This is a new and exciting leadership role within hospital transitional programs working with 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.
Act as the primary point of contact for the hospital navigator/coordinator
Receive, monitor and update the client tracking/notification/flow tools
Receive, review, and accept referrals for in-home transition services
Coordinate/Liaise with hospital navigator/coordinator and SE @home Team as required.
Participate in hospital discharge care conference for complex clients as required
Prepare an initial care plan (e.g. for 48-72 hours post transition) and place an initial equipment and supplies order as required
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
Attend program huddles with hospital (as per contract requirements)
Monitor and communicate significant deviations from the care plan to the hospital as required.
Communicate to the hospital any risk-related events
Monitor timely completion and reporting outcomes of patient/family care conferences to partner hospital(required in contract)Monitor Program Metrics (e.g. client experience, time to first visit, service volumes, risk events, etc.)
Facilitate risk management as per established policies and procedures
Communicate patient and family complaints or issues back to partner hospital and share associated action plans in partner meetings
Participate in program evaluation and process improvement
On-call as required for programs support
Other duties to ensure program is running smoothly
Membership, in good standing, with the applicable regulatory body:
College of Nurses of Ontario.
College of Physiotherapists of Ontario.
College of Occupational Therapists of Ontario.
Ontario College of Social Workers and Social Service Workers.
3+ years of recent experience in community health or a related field.
Ability to work evenings and weekends
Knowledge of the health care delivery system including hospital discharge planning, community care and support services
Excellent skills in case management and coordinating care within interdisciplinary teams
Excellent assessment and decision-making skills
Passion for excellent customer service and customer experience
Demonstrates strong critical thinking, problem-solving and self-directed skills.
Excellent interpersonal communication, and presentation skills with a diverse group or stakeholders (hospital partners, front line staff, management team)
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).
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)
A valid driver’s license and access to a reliable vehicle.
About SE Health
SE Health (Saint Elizabeth Health Care) is a social enterprise applying our knowledge, vision and drive to forever impact how people live and age at home, today and into the future. As a not-for-profit organization with Canadian roots and 110 years of expertise, we bring quality excellence and innovation to home care, seniors lifestyle and family caregiving. Through our team of 9,000 Leaders of Impact, we deliver 20,000 care exchanges daily, totaling 50 million in the last decade alone. In 2019 we were honored to be recognized by Forbes as one of Canada's Best Employers.
Saint Elizabeth 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 Human Resources at firstname.lastname@example.org at your earliest convenience.