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Community Lead
4 months ago
An 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.
Hybrid role (virtual /in-person) covering North Toronto and York Region, primarily in Vaughan and Richmond Hill.Hours are primarily during business hours Monday-Friday and can also be irregular and include on-call to support operational requirements.
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/coordinatorCoordinate/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
Membership, in good standing, with the applicable regulatory body:
- Ontario College of Social Workers and Social Service Workers.
~ 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 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 s k ills in M ic rosoft Off i ce (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.
Every day, we bring hope and happiness to clients, homes, and communities across Canada.
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.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 .
