Integrated Care

2 weeks ago

Toronto, Canada University Health Network Full time

**JOB POSTING # 915742**

**Position: Integrated Care (IC) Lead**
**Site: Toronto General Hospital or Toronto Western Hospital**

**Hours: 37.5 hours per week; predominant day shifts Mon - Fri with requirement including on-call, as well as evenings and/or weekend shifts.**
**Salary Range: $39.20 to $49 per hour**
**Status: Permanent Full-Time, contingent on funding**

**THIS IS A PIPELINE POSTING FOR FUTURE OPPORTUNITIES**

**University Health Network (UHN)** is looking for experienced professionals to fill key roles of Integrated Care (IC) Lead** **for Surgery

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

The University Health Network, where _“above all else the needs of patients 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.

To **inspire, invent and deliver tomorrow’s care** the Integrated Care Program looks beyond our walls and identifies and integrates the health and well-being services and supports to provide comprehensive care to our patients. The program leverages an integrated delivery model, care team, health record and funding model to optimize patient care outcomes, as well as optimize efficiency and costs for providers. The integrated care team supports patient care and seamless transitions from community to hospital and back to community, including ongoing community management.

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

***:
**RESPONSIBILTIES INCLUDE**:

- Acting as the key lead liaising between patients, the UHN clinical team, community providers, primary care providers, and other providers, to ensure all components of a patient’s care are provided.
- Developing, supporting and overseeing a patient’s care path through the various care settings to ensure continuity of care.
- Providing mentorship, coaching and ongoing clinical knowledge transfer to care team members, including home and community partners regarding the IC Program and its patients.
- Provide home visits when required to facilitate patient 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, including home and community care, to ensure ongoing assessment and adjustment to support patient needs.
- Coordinating seamless care transitions through appropriate and effective exchange of knowledge related to respective health conditions and the continuum of services and resources to enhance patient self-management and quality of care.
- Monitoring to ensure that the patient and system level objectives of the bundle of care 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 clinical experience required, experience in a community health setting preferred
- Five (5) years of recent, related acute care setting experience required.
- Demonstrated experience and competence in areas of patient need relevant to:

- Surgery including: thoracic, head and neck, cancer, orthopedics, general surgery, neurosurgery, and/or others, and a willingness to learn or existing knowledge regarding other surgical pathways an asset
- Medicine including: congestive heart failure, chronic obstructive pulmonary disease, chronic and complex older adult care, oncology and a willingness to learn or existing knowledge regarding other patient populations an asset
- Demonstrated experience and competence in case management is preferred.
- Demonstrated recent comprehensive knowledge of community resources and health care delivery systems in acute and community settings is preferred.
- 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 patients and situations with resourcefulness, flexibility and adaptability is required.
- Excellent interpersonal, communication, organizational and decision-making skills required.
- De

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