Transition Coordinator

3 weeks ago

Toronto, Canada Holland Bloorview Kids Rehabilitation Hospital Full time

The Transition Coordinator is responsible for providing leadership related to transition planning for inpatient services and strives to deliver an exceptional client/family experience throughout their healthcare journey. This involves working collaboratively with the client/family, internal and external partners to achieve a well-coordinated, comprehensive, client centered seamless transition plan.

The Transitional Care for Medically Complex Children Program is transforming community care through innovate transitional programing. Holland Bloorview as a health care provider organization in partnership with Safehaven, a service provider, oversees transitional care beds in the community.

The transition coordinator provides system navigation for clients and families as they move from acute care services to rehab services and then as they integrate into the community and-or home Clients may range from birth to 18 years of age with a variety of medically complex conditions including brain injury, spinal cord injury, orthopaedic surgery and other developmental conditions which require medical technology..

The transition coordinator utilizes their knowledge and understanding of health care system and community resources to enhance operational effectiveness of the inpatient units while supporting seamless and safe transitions. They are strength based and solution focused in their approach to community integration. The transition coordinator provides education on the transition process and community services to clients, families and teams to ensure a safe transition for each client and family.

**Key Responsibilities**

**Clinical Practice**:

- Guides the eligibility criteria for program admission, evaluate program admissions in partnership with Safehaven and manages wait lists.
- Assesses the transition needs and goals of the client and family in partnership with the team
- Coordinates smooth and seamless transitions for clients and families between and across services
- Develops a timely, effective and safe transition plan in collaboration with clients, families and interdisciplinary teams
- Provides case management and care coordination activities as appropriate
- Documents transition plan and activities
- Communicates effectively with clients and families and members of the interprofessional health care team
- Participates in and/or leads complex admission and transition planning processes
- Participates in systems improvement and innovations to ensure access and efficient use of clinical transition services

**Interprofessional Collaborations**:

- Collaborates with interprofessional team members, clients and families as well as community healthcare providers and agencies to achieve seamless transitions
- Participates in quality improvement initiatives and committees
- Collaborates and participates in planning, promoting, implementing and evaluating new ideas, concepts, and interventions to facilitate transition for clients and families
- Provides support and expertise to health care team on transitions and community resources
- Builds collaborative relationships with key partners (e.g. SickKids, LHIN Home & Community Services, and other referring partners)

**Leadership**:
The transition coordinator_ _will use strength based leadership to develop themselves and engage others, build partnerships and networks to achieve results, and use systems/critical thinking to champion and orchestrate change.
- Provides leadership in the area of transitions and is a resource person and role model for the interprofessional team
- Guides, initiates and provides leadership to support operational effectiveness and client flow(e.g. LOS, wait times)
- Participates in professional, program and hospital-wide initiatives
- Actively promotes professional role through participation in external forums
- Examines current processes, identifies opportunities for change and provides recommendations for improvements

**Research and Education**:

- Uses evidence in practice, develops and uses clinical practice guidelines, pathways and protocols in transition planning and service delivery
- Participates in quality improvement and research activities as required
- Functions as a content expert and resource person in their specialized field of practice, and takes advantage of informal and formal learning opportunities to educate the interprofessional team
- Educates clients, families, members of the health care team, referring facilities and other community providers
- Enhances personal and professional development through reflective practice and by attending educational opportunities and /or conferences

**Qualifications**

**Education**
- Degree in a regulated health care profession, preferably social work, Master’s Degree preferred

**Experience**
- Minimum 3 years pediatric and experience working with families required
- Experience working with children with disabilities preferred

**Skills**
- Strong knowledge base related to current

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