Care & Transitions Facilitator - Cath Lab (Perm Ft)

2 weeks ago

Toronto, Canada St. Michael's Hospital Full time

The Care & Transitions Facilitator is a practitioner in the Heart and Vascular program that is results oriented committed to enhance the quality of patient care within a complex health, social and fiscal environment. As a clinical expert, you will be instrumental in coordinating the use of clinical resources for patients being considered for mínimally invasive coronary & structural heart procedures. Working collaboratively with interdisciplinary teams, you will be responsible for facilitating the patient journey from referral to our coronary & structural heart teams to procedure through assessment, care planning, transitions and evaluation of care for the patient population. A key component of the role is organization of testing and/ or care for all patients referred
- Other duties include:

- Patient assessment and triage inclusive of being a resource for patients to call with questions through their care journey
- Educating patients/families, students, Residents and new staff;
- Coordinating multiple referrals through testing and care pathways;
- Networking and building community and internal partnerships;
- Identifying and leading unit based quality initiatives.

**RESPONSIBILITIES**:

- Care Facilitation:_
- Working with the Coronary & Structural Heart Teams, you will:_
- Assess the needs of patients and families working to advance all patient journeys in order to reduce delays in service/disposition for coronary & structural heart patients from referral to procedure and beyond.
- Lead weekly clinic (if applicable), managing and coordinating the patients, their tests and the interdisciplinary team.
- Ensure development, implementation and evaluation of intra-disciplinary care plans for patients with clear treatment goals including schedules/routines
- Coordinate clinical resource use for exceptional and complex patients
- Communicate effectively with medical/interdisciplinary/unit teams and patients/families adjudicating daily plans of care to enrich patient progress
- Coordinate care delivery with internal and external stakeholders liaising with outside agencies to facilitate the initiation of timely and appropriate medical, functional testing and services
- Advocate for patient services needed for a safe and effective care from referral to procedure and beyond.
- Negotiate care pathways for patients experiencing limited services or space
- Identify patient care/safety issues working to resolve issues and communicate concerns to the MRP or unit Clinical Leader Manager (CLM)
- Utilize expert knowledge and leverage external resources to reduce system barriers and facilitate safe and timely care and testing.
- Under the direction of the CLM, act as a resource for patient care issues and problem solve in collaboration with cross program and community teams to ensure effective and efficient patient testing, care, access, flow, and transitions in care
- Education:_
- Provide direct patient education about their mínimally invasive coronary & structural heart procedures.
- Educate patients and families with regards to the patient journey of care inclusive of coordination of testing, care, and transitions.
- Facilitate communication of changes in practice, protocols, education and other relevant material to Hospital staff/physicians
- Under the direction of the CLM act as clinical resource for the interdisciplinary team and front line staff
- Encourage the coronary & structural heart team’s active involvement in patient care plan and discharge activities
- Collaborate with CLM to engage staff and physicians to reach consensus related to care by providing direct or indirect assistance, guidance or supervision along the continuum of care
- Quality Improvement/Research:_
- Update knowledge by participating in educational opportunities, reading professional publications, maintaining personal networks, participating in professional organization
- Support the CLM and team in the implementation of unit/program based quality improvement initiatives and development of best practice pathways.
- Facilitate a multidisciplinary approach to quality and cost-effective complex patient care in the acute outpatient setting
- Offer strategic counsel to program leaders and unit staff to assist in prioritizing care issues related to patient flow, utilization, wait-list status as well as system issues/barriers through analysis of core metrics such as, but not limited to: Ambulatory volumes, wait lists and individual patient barriers to care.
- Identify/analyze care practices & system processes that contribute to/impede outcomes and make recommendations related to evaluation and redesigning processes
- Collaborate with the Program research teams to identify patients for clinical trials and support and coordinate the tests and procedures involved.
- Administrative:_
- Develop care management tools (assist in development of care maps/patient protocols for high volume procedures/diagnosis)
- Participate in internal and external comm

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