Integrated Care

4 weeks ago

Toronto, Canada University Health Network Full time

**JOB POSTING #: 913185**

**Position: Integrated Care (IC) Lead**
**Site: Toronto General Hospital or Toronto Western Hospital**
**Location: Connected Care Hub, Travel between NORC building sites will be required**

**Hours: 37.5 hours per week; there may be some on-call, as well as evenings and/or weekend shifts.**
**Salary Range: $39.20 to $49 per hour (Commensurate with experience and consistent with the UHN compensation policy)**
**Status: Permanent Full-Time, contingent on continued funding**

**University Health Network (UHN)** is looking for an experienced professional to fill the key role of Integrated Care (IC) Lead for the NORC Innovation Centre

**_
Transforming lives and communities through excellence in care, discovery and learning._**

The University Health Network, where “above all else the needs of seniors come first”, encompasses Toronto General Hospital, Toronto Western Hospital, Princess Margaret Cancer Centre, Toronto Rehabilitation Institute and the Michener Institute of Education at UHN. The University Health Network (UHN), Canada’s largest research teaching hospital, brings together over 16,000 employees, more than 1,200 physicians, 8,000+ students, and many volunteers. UHN is a caring, creative place where amazing people are amazing the world.

If you have a passion for improving senior care and the desire and energy to make change in health and social please consider joining us.

***:
**RESPONSIBILITIES INCLUDE**:

- Passionate about senior self-management, agency, and ability to live independently
- Advocate for a senior’s specific health and social care, including all aspects of determinants of health
- Champions transdisciplinary integrated health and social care approaches
- Liaise closely with the on-site NORC Hub Coordinator, the Connected Care Hub NP, and the clinical team to ensure a smooth seamless experience for seniors.
- Acting as the key lead liaising between seniors, the UHN Connected Care Hub, community providers, primary care providers, and other providers, to ensure all components of a senior’s care are provided.
- Developing, supporting, and overseeing a senior’s care path through the various care settings to ensure continuity of care.
- Providing mentorship, coaching, and ongoing health and social care knowledge transfer to care team members, and care partners regarding the IC Program and its seniors.
- Provide home visits when required to facilitate senior care and/or in-home training and support for homecare team.
- Working collaboratively with an inter-professional team, family members, support network, and a variety of informal and formal service providers, to ensure ongoing assessment and adjustment to support senior needs.
- Coordinating seamless care transitions through the appropriate and effective exchange of knowledge related to respective health and social conditions and the continuum of services and resources to enhance senior self-management and quality of care.
- Monitoring to ensure that the senior and system-level objectives of the NORC Integrated Health and Social Care model are met.
- Leading ongoing innovation and optimization efforts with regular monitoring of Program data and metrics, synthesizing data to make recommendations or act upon trends or patterns to inform care planning.
- Works within UHN’s Safety and Quality policies and procedures.
- Provide cross-coverage of other IC Programs and pathways.

**QUALIFICATIONS**:

- Undergraduate/Graduate degree in a related health profession.
- Current membership in good standing with applicable/relevant regulatory health professional body in Ontario is required.
- Five (5) years of geriatric experience required including experience in a community health setting
- Five (5) years of recent community experience required.
- Demonstrated experience and competence in areas relevant to senior health and social care in the community including holistic care across all facets of health and social care, understanding various screening and assessment tools to identify risks associated with common community health and social issues
- Demonstrated willingness and ability to use new assessment tools and systems as required by the Ministry or in keeping with legislated requirements.
- Demonstrated ability to quickly respond to seniors and situations with resourcefulness, flexibility, and adaptability is required. Experience with advanced care planning and palliative approaches to care preferred
- Experience with crisis intervention preferred
- Demonstrated experience and competence in community health and social care management is preferred.
- Demonstrated recent comprehensive knowledge of community resources and health care delivery systems in acute and community settings is preferred.
- Excellent interpersonal, communication (verbal and written), organizational, and decision-making skills are required.
- Demonstrated leadership skills, including problem-solving, critical thinking, conflict resolu

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