Transitional Care Manager

2 weeks ago

Toronto, Canada SPRINT Senior Care Full time

**Supervisor, Transitional Care**

**About SPRINT Senior Care**:
We began caring for seniors and enabling seniors to care for themselves in 1983. We continue to do so today as an accredited, not-for-profit community support service agency in Toronto by offering a wide range of practical and low-cost services to seniors and their caregivers. Our services help seniors stay safe, connected, and live as independently as possible. They also prevent premature or inappropriate institutionalization. We supply services regardless of ability, race, colour, ethnic origin, marital status, sexual orientation, religion, gender identity and gender expression, and are committed to 2SLGBTQ+ inclusiveness.

**Program Description**:
The Transitional Care team via a collaborative partnership with Sunnybrook Hospital supports the transition of patients from hospital to community or other appropriate place of care. This community-based model of care enables clients to receive clinical support and/or regain strength and independence outside of hospital. The goal is to help clients and their caregivers make informed and sustainable decisions about their future care needs and living arrangements.

**What you will do**:
The Supervisor, Transitional Care supervises coordination of case management services and both direct and indirect services to support the physical, cognitive, and mental health needs of older adults and seniors. This role would include, but is not limited to, the following activities:

- Coordinate health services and social support interventions for clients, families and caregivers.
- Develop realistic and innovative transitional plans for reintegration back to the community, LTC or alternative right place of care.
- Work with the client and other professionals to improve the client’s ability to complete the activities of daily living at home and/or another community setting.
- Enhance confidence in the client’s ability to return home safely to and thrive in the community.
- Connect with current and new community services based on needs.
- Support the Manager, Transitional Care with to identify appropriate/eligible clients who need support and assistance in transitioning home or to other appropriate places of care.
- Provide support to hospital staff in completing the necessary referral forms, where applicable.
- Provide information about this transitional supportive housing to clients and caregivers.
- Oversee the successful completion of all client assessments, reassessments, and care plans, including Ministry requirements for interRAI-CHA Assessments.
- Provide crisis intervention as needed.
- Provide back up and coverage for the Manager, Transitional Care.
- Assist and support the manager in completing all required client care statistical tracking.
- Assist and support the manager in overseeing the planning, coordination and facilitation of caregiver support through the provision of self-help, therapeutic, problem-solving, and educational group programs.
- Maintain excellent collaborative relationships with referral sources and resources.
- Participate in the development, implementation and evaluation of quality and risk management activities of the department and agency.
- Ensure that the agency’s programs and services are delivered within the agency’s mandate, mission, vision and values, objectives, and policies and procedures, within relevant legislative requirements.
- Off hours may be occasional required based on client needs. Ability to work flexible hours as required.

**What you will need**:

- BSW, or other related professional designation.
- Minimum of two years of experience working in gerontology and/or community setting.
- Strong supervisory skills.
- Excellent communication and interpersonal skills, with the ability to establish good rapport with staff, clients, families, and referral sources in a multi-cultural setting.
- Excellent understanding of the aging process, dementia and the specific needs of the elderly, disabled and caregivers.
- Experience working with individual caregivers.
- Sensitive to the cultural needs of clients from various ethnic groups.
- Committed to SPRINT Senior Care's philosophy of care, with the ability and empathy to work with people with dementia, and mental health and addictions.
- Experience in community capacity building, health promotion, adult education, or social group work.
- Self-directed, results oriented and capable of working independently as well as in a team environment.
- Excellent organizational, facilitation, conceptual, strategic, and problem-solving skills.
- Excellent knowledge of program evaluation, risk management and quality improvement strategies.
- Proven ability to establish and maintain productive working relationships internally and externally with stakeholders and partnering agencies.
- Demonstrates an intermediate level for database concepts and structures.
- Familiarity with CIMS (Client Information Management System) database is

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