Coordinator, Integrated Transitions

2 weeks ago

Toronto, Canada North York General Hospital Full time

Company Bio
IMAGINE a hospital where everyone is committed to excellence. We did. We are. From boardroom to bedside, we go above and beyond to offer the best and safest patient care. At North York General Hospital (NYGH), we put our patients first in everything we do. We are achieving a new standard of excellence in integrated patient-centered care and as one of Canada's leading community academic hospitals, we are building on our academic foundation through enhanced education, research and innovation. North York General Hospital is part of North York Toronto Health Partners, a collaborative partnership with patients, primary care, and community partners, a first
- generation Ontario Health Team, driving the development of a locally integrated health system to serve the community. As part of our dynamic team, you too can stand out and be amazing At North York General, our team is making a world of difference.
Position Summary
Coordinator, Integrated Transitions
Your goal in this position is to provide clinical support, patient and family education and comprehensive care facilitation for the NYCARES integrated care initiative. The NYCARES program will operate in an integrated partnership model with Home and Community Support Services and other community care providers. In this role, you will identify and facilitate access to the right health and social services by collaboratively working with an inter-professional team, primary care, family members and caregivers, support network, and a variety of service providers. In addition, you will be responsible for exchanging knowledge amongst partners related to patients participating in the NYCARES program by ensuring access to an integrated continuum of services and by providing an excellent patient and caregiver experience. In this role, you will be an innovator, a champion for building excellent care experiences and a collaborator with the ability to bridge multiple stakeholders to meet the needs of those who are receiving care in the home. This position supports the hospital’s academic mandate by advancing care through teaching and learning and/or transforming care through research and innovation. This position contributes to the shared responsibility of ensuring health and safety policies are followed to provide for a healthy environment for staff, physicians, volunteers, learners, patients, and families.

This role is also key to NYG’s Ontario Health Team, North York Toronto Health Partners, mandate to create a more Compassionate North York, improving population health for our community through more coordinated, integrated care across the continuum. The incumbent will be an experienced healthcare professional with demonstrated ability to collaborate with internal and external partners, have strong community and hospital understanding and operational experience and has a passion for geriatric care.
On a practical level, you will
Onboard eligible NYCARES program patients which will include patient and caregiver engagement and education
- Support patient navigation related to the delivery of care pathways including assessments, planning, implementation, evaluation, and documentation throughout the entire episode of care
- Coordinate with hospital and community staff to facilitate discharge planning meetings and will follow up with primary care providers, hospital physicians and specialists as needed
- Ensure timely patient access to appropriate appointments, tests and follow up across the episode of care
- Use your clinical expertise, critical thinking and decision making to direct or modify care pathways to meet patient needs as required
- Facilitate advance care planning with the most appropriate provider
- Lead and facilitate regular inter-professional patient care rounds and case conferences with acute and community team members as needed
- Be the primary contact for patients, families and care providers in the hospital and the community
- Enable the flow of information in adherence with privacy legislation
- Facilitate and support seamless transitions across the care continuum
- Contribute to and support the hospital’s and OHT mission, vision, values, and strategic direction
- Interpret hospital policies, professional standards, and relevant legislatio

**Qualifications**:
Regulated healthcare professional required
- Current registration, in good standing with the applicable college required
- Minimum three (3) years’ community care experience
- Demonstrated expertise in the management and care coordination for seniors, patients with complex care needs, chronic diseases, mental health, and addictions and/or palliative care
- Experience providing patient education
- Strong commitment to Patient and Family Centered Care
- Expert clinical skills in the assessment, planning, implementing, evaluating, and documenting of the delivery and coordination of care for patients and their families living with chronic disease and/or elderly patients with medical

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