The Transition Navigator for Kew Beach is a staff member of MGH working in the community providing comprehensive, patient centred transition planning for Michael Garron patients residing in Kew Beach residence. The Transition Navigator is a key member of the interprofessional team, focusing on the provision of excellence throughout the transition process. The Transition Navigator collaborates with acute care TNs on the patient transition from hospital to Kew Beach residence and then on to the next destination of care. The TN is responsible for developing a plan that considers the needs of the patient from a: cultural; financial; social; and spiritual perspective. The Transition Navigator works toward a seamless and sustainable transition, while utilizing their knowledge and understanding of community resources, legislation as it relates to Alternative Level of Care (ALC), Substitute Decision Makers Act, Public Guardian and Trustee and the Public Hospitals Act to reduce patient length of stay and readmissions rates. The Transition Navigator provides education and uses teach-back methodology to ensure health literacy is embedded into the transition process, with follow-up discharge phone calls at regular intervals, to ensure a smooth transition.
- Bachelors degree in a healthcare field.
- Registration in good standing with relevant professional college.
- 2-3 years recent experience in healthcare in a professional field required
- 2 years recent experience in transition/discharge planning required
- Working knowledge of community resources, LHIN Home and Community Care, long term care facilities, rehabilitation and palliative care facilities/programs required
- Experience working with the geriatric population
- Demonstrated knowledge and skills in transition/discharge planning, conflict resolution and creative problem solving required
- Demonstrated working knowledge of legislation including the Substitute Decision Makers Act, Alternative Level of Care, Public Hospitals Act
- Experience working with the Resource Matching and Referral system and electronic documentation systems
- Demonstrated ability to prioritize multiple competing workload demands
- Superior communication and negotiation skills
- Demonstrated ability to provide resource identification, referral and linking
- Demonstrated ability to work collaboratively as a member of aninterprofessional team
- Demonstrated ability to build relationships with internal and external partners.
- Demonstrated patient centered philosophy of care provision
- All employees of Michael Garron Hospital (MGH), a division of Toronto East HealthNetwork (TEHN) [formerly Toronto East General Hospital (TEGH)] agree to work within the legislated practices of the Occupational Health and Safety Act of Ontario.
- All employees of MGH are responsible to contribute to a transparent culture of patient and staff
safety by adhering to and abiding by patient and staff safety policies and procedures set by MGH.
- All employees are accountable for protecting the psychological healthand safety of themselves and their co-workers through adherence to MGH's policies and practices.