SCOPE/LTC Navigator

Humber River Health. Lighting New Ways In Healthcare.

Since opening our doors in 2015 as North America’s first fully digital hospital, we remain unwavering in our belief that we can change the hospital where we work, the community where we live, and the world of healthcare beyond our borders. Serving a community of 850,000 residents in North West Toronto, Equity Inclusivity and active participation in the North West Toronto Ontario Health Team are key initiatives important to our Team. At Humber River Health, we use a custom combination of technology and clinical expertise to rebuild elements of care. We make technology work for staff and physicians; giving them more time to spend with patients, to eliminate inefficiencies, and to reduce the chance of errors. Humber River Health is formally affiliated with both the University of Toronto and Queen’s University and committed to becoming a community academic hospital. Clinical Excellence, Optimizing Care through Technology and Community Connection frame our Research Strategy.

At Humber River Health, we’re not hoping for a renaissance, we are making it happen. As part of our dynamic team, you can lead the way, as we continue our journey towards high reliability care

We have an exciting opportunity for a Temporary Part-Time SCOPE/LTC+ Navigator to join our team within Integrated Health Systems & Partnerships at Humber River Health . This department works collaboratively with internal departments, community partners, primary care, agencies, Ontario Health and the Ministry of Health to plan and build an Integrated Health System to improve the health of our community. SCOPE (Seamless Care Optimization the Patient Experience) is a quality improvement collaboration between the hospital and primary care providers (PCPs) located in North West Toronto. The SCOPE service is a virtual inter-professional team that facilitates greater access to hospital-based interdisciplinary resources and other specialists care. SCOPE aims to reduce avoidable ED visits and hospital re-admissions for patients in need. LTC+ (Long Term Care +) is a virtual care model that provides direct access to a suite of services including real-time access to virtual GIM consultations, specialist care and community resources for the partner LTC homes in North West Toronto. LTC+ aims to deliver the best care possible to residents in LTC homes to avoid unnecessary transfers to hospital and improve access to outpatient clinics/resources.Reporting to the Manager, Family Medicine Teaching Unit and Integrated Care Services, the SCOPE/LTC+ Navigator will coordinate and assist physicians in primary care and in Long Term Care Homes in navigating SCOPE services, providing centralized access to hospital and community services, with follow-up on status of referrals, results, and consults. This role supports timely access, ensures navigator to appropriate resources, and reduced ED visits as patients are proactively connected to the right level of care

Employment Status: Temporary Part-TimeDuration: March 2025 (subject to change per Management Rights)Hours of Work: Days/Afternoons (subject to change); weekend work will be required.Location: Humber River Health, Wilson SiteLabour Group: Non-UnionReporting Relationship: Manager, Family Medicine Teaching UnitRESPONSIBLITIES • Play a leadership role in the implementation, monitoring, and evaluation of the SCOPE and LTC+ program• Participate in the implementation, monitoring, and evaluation of the SCOPE/LTC+ program• Participates in internal and external committees/working groups• Enhance work-flow and communication pathways between hospital, primary care and community care by identifying barriers to care and work towards creating new care pathways to promote and optimize seamless care for the client.• Advocate for, and contribute to, the establishment of organizational structures and resources to support the growth of SCOPE and LTC+ in keeping with the direction and priorities of the organization• Advocate to identify gaps in services, needed for individualized program consideration and system level changes required to meet changing needs of the patient population• Develop and foster links with external partners to facilitate continuity of patient care; including community outreach • Respond to all calls and emails made to SCOPE/LTC+ Navigation Hub by the PCPs, LTC physicians and Nurse Practitioners and their administrative assistants• Assist Primary Care Providers in the community and LTC with system navigation, referrals to specialists, and resources in the community, and other appropriate community, clinical and specialized supports to address patient health concerns.• Ensure seamless navigation of existing services; triage and forward referrals to appropriate SCOPE/LTC+ contact (i.e. Internist, Home and Community Care Coordinator, Imaging, Outpatient Clinics)• Collaborate with the health care team to improve patient care as they transition through the health care system• Collect relevant patient information required for assessment and database entry (Patient Name, DOB, HC#)• Understand and clarify PCP primary concerns and request for support• Work collaboratively and in relationship with the inter-professional team while role modelling relationship centered care• Use concepts from complexity thinking and relational inquiry when in relationship with others.• Collect Data for research evaluation for each referral - Database Entry forms to be completed with each referral and submitted to the evaluation team on a weekly basis• Review available/relevant information from Meditech (EMR) to determine assessment and care planning• If client is an existing or former clinic patient, will re-connect with staff to communicate PCP concerns and request for assessment• This includes the clarification of referral criteria and identification of the resource that will best suit the health care need• Improve communication and collaboration between consultants and primary care services by assisting PCP staff in the compilation of referral packages and follow-up of referrals• Provide PCP or PCP staff with clinic/referral information• Navigate hospital clinics and resources that will assist PCP with managing client medical, functional, cognitive, psychosocial conditions• Direct requests for Internal medicine consultations or medical work-ups to SCOPE/LTC+’s Internist-On-Call• Coordinate care delivery and the development of individualized care plans with the persons internal and external stakeholders including liaising with outside agencies to facilitate seamless care for persons across sectors - primary, acute and community careREQUIREMENTS

• Bachelor of Science in Nursing • Masters in Nursing or a related discipline• Current registration and membership in good standing with the College of Nurses of Ontario• Minimum of 3 years of experience within acute care and/or primary/community care• Written and verbal communications with ability to explain and provide necessary information to patients, family members, physician and/or any stakeholders• Experience working within an interprofessional team environment as well as independently• Experience working with older patients with complex needs • Demonstrated computer skills using MS Office (Outlook, Word, Excel, PowerPoint, Visio, etc.)• Database management skills preferred with strong written and oral interpersonal skills• Understand and appreciate primary care challenges• Respectful, responsive communication system, able to communicate with front-line staff, primary care providers and specialist offices• Evidence of program design and resources development skills, including knowledge of evaluation methodologies • Highly Organized with the ability to multitask • Strong work ethic - committed to task completion and follow through • Ability to be flexible and adapt to a changing environment assuming responsibility for own learning • Excellent team player • Excellent attendance and discipline free record required.

We thank all candidates that apply, only qualified candidates will be contacted for an interview

Why choose Humber River Health?

At Humber River Health, our staff, physicians, and volunteers are lighting new ways in healthcare. We are proud to be recognized as a part of Greater Toronto’s Top Employers by Mediacorp Canada Inc. We support employees by providing evidence-based leadership and cultivating a culture that consistently wows as a Huron Consulting hospital. We are a member of the Toronto Academic Health Science Network (TAHSN) and are deeply involved in research and academic collaboration. We are dedicated to high-quality patient care and demonstrate our values of compassion, professionalism, and respect.

Attracting and retaining a workforce that represents the diverse communities surrounding Humber River Health, is a priority. We encourage applicants from all equity-deserving groups, including but not limited to, individuals who identity as Indigenous, racialized, seniors, persons living with disabilities, women, and those who identify as 2SLGBTQ.

Applicants will not be discriminated against on the basis of race, creed, sex, sexual orientation, gender identity or expression, age, religion, disability, medical condition, or any protected category prohibited by the Ontario Human Rights Code and Accessibility for Ontarians with Disabilities Act.

Accommodations are available throughout the recruitment process as well as during employment at Humber River Health. Please direct any accommodation requests to our recruitment team.