Transitions Care Lead

OverviewThe Acute Care Transitions Program ensures seamless, compassionate care as patients move from hospital to home. Designed to support both patients and their families, the program connects individuals with community-based healthcare providers, social support services, primary care and acute care teams. Together, they create personalized plans that improve outcomes and ease the transition to home.Position SummaryRemote role12 Months contract role -12 hour shift with every other weekendAs 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 position will manage relations and collaborate with hospitals to ensure a smooth and seamless transition to a client’s home environment. You will also help ensure performance targets are met and be involved in quality improvement initiatives as they relate to optimizing patient flow and management processes within the Acute Transition programs.Why join our team?Competitive compensation. Our Total Rewards package includes a competitive salary, group benefits, RRSP pension, on demand pay and exclusive perks/discounts available only to SE Health staffDevelop yourself with SE. We have education bursaries, Tuition Assistance Programs, continuing education, training, and professional development to support your lifelong learningGrow your career. SE Health is a large national organization with diverse healthcare business lines. You’ll have an opportunity – and will be supported – to do different types of patient-facing nursing roles in different locations if that is what you’re interested in. Or you can pivot to supporting or leadership positions where you use your nursing skills as a foundation to contribute and make an impact in different ways.Manage your life. At SE, you’ll have the flexibility to manage your schedule to balance your life. You’ll be supported with the time you need to meet the needs of your clients, meet your own needs, develop yourself and your career, and be part of a teamPaid mileage between clients.Subsidized RNAO & RPNAO membershipsMobile device and 3 uniforms providedResponsibilitiesAct as the primary point of contact for the hospital navigator/coordinatorReceive, monitor and update the client tracking/notification/flow toolsReceive, review, and accept referrals for in-home transition servicesCoordinate/Liaise with hospital navigator/coordinator and SE @home Team as requiredParticipate in hospital discharge care conference for complex clients as requiredPrepare an initial care plan (e.g. for 48-72 hours post transition) and place an initial equipment and supplies order as requiredEnsure 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 TeamAttend program huddles with hospital (as per contract requirements)Monitor and communicate significant deviations from the care plan to the hospital as requiredCommunicate to the hospital any risk-related eventsMonitor 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 proceduresCommunicate patient and family complaints or issues back to partner hospital and share associated action plans in partner meetingsParticipate in program evaluation and process improvementOn-call as required for program supportOther duties to ensure program is running smoothlyRequirementsMembership, in good standing, with the applicable regulatory body:College of Nurses of OntarioCollege of Physiotherapists of OntarioCollege of Occupational Therapists of OntarioOntario College of Social Workers and Social Service Workers3+ years of recent experience in community health or a related fieldKnowledge of the health care delivery system including hospital discharge planning, community care and support servicesExcellent skills in case management and coordinating care within interdisciplinary teamsExcellent assessment and decision-making skillsPassion for excellent customer service and customer experienceDemonstrates strong critical thinking, problem-solving and self-directed skillsExcellent interpersonal communication, and presentation skills with a diverse group of 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 vehicleAbout SE HealthAt 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 caree… #J-18808-Ljbffr