Transitions Care Lead

1 month ago

North York, Canada SE Health Full time

**Make an Impact on People’s Lives; Join SE Health as a **Transitions Care Lead****

This is an exciting SE Health role providing clinical and operational leadership to hospital to home transitions programs and coaching self-directed interdisciplinary teams who will be providing holistic care to clients in the community.

As the Transitions Care Lead You will provide exemplary leadership and care flow management between the hospital partners and community care teams while ensuring excellence in the provision of client care and the achievement of corporate/program objectives. This exciting position will manage relations and collaborate with hospitals to ensure a smooth and seamless transition to a client’s home environment. Additionally, this position will help to ensure performance targets are met and be involved in quality improvement initiatives as it relates to optimizing patient flow and management processes within the Acute Transition programs.

**The position is 14 months contract role**

**Why join our team?**
- **Competitive Compensation**. Our Total Rewards package includes a competitive salary, group benefits, RRSP pension, and exclusive perks/discounts available only to SE Health staff.
- **Develop yourself with SE.** We have education bursaries, Tuition Assistance Programs, continuing education, training, and professional development to support your life-long learning. You’ll benefit from our orientation and mentorship programs. Our clinical practice and nursing teams will support you with comprehensive care plans and modern models of care that will mean you’ll always be supported to provide the best possible care to your clients.
- **Grow your career.** SE health is a large national organization with diverse healthcare business lines. You’ll have an opportunity - and will be supported - to do different types of roles in different locations if that is what you’re interested in. Or you can pivot to supporting or leadership positions where you can use your skills to contribute and make an impact in different ways.

**Key Responsibilities**
- Act as the primary point of contact for the hospital navigator/coordinator
- Receive, monitor, and update the client tracking/notification/flow tools
- Receive, review, and accept referrals for transition program services
- Coordinate/Liaise with hospital navigator/coordinator and SE Transitions Team as required.
- Participate in hospital discharge care conferences for complex clients as required
- Prepare an initial care plan (e.g. for 48-72 hours post-transition) and place an initial equipment and supplies order as required
- Ensure all necessary referral documents (e.g. transition request form, medical orders, consult notes, allied health reports) and initial care plan instructions are received by SE Transitions Team
- Attend program huddles with hospital (as per contract requirements)
- Monitor and communicate significant deviations from the care plan to the hospital as required.
- Communicate to the hospital any risk-related events
- Monitor timely completion and reporting outcomes of patient/family care conferences to partner hospital (required in contract) Monitor Program Metrics (e.g. client experience, time to first visit, service volumes, risk events, etc.)
- Facilitate risk management as per established policies and procedures
- Communicate patient and family complaints or issues back to partner hospital and share associated action plans in partner meetings
- Participate in program evaluation and process improvement
- On-call as required for program support
- Other duties to ensure the program is running smoothly
- Role is on-site at the hospital

**Qualifications**
- Membership, in good standing, with the applicable regulatory body:
College of Nurses of Ontario.

College of Physiotherapists of Ontario.

College of Occupational Therapists of Ontario.

Ontario College of Social Workers and Social Service Workers.
- 3+ years of recent experience in community health or a related field.
- Knowledge of the health care delivery system including hospital discharge planning, community care, and support services
- Excellent skills in case management and coordinating care within interdisciplinary teams
- Excellent assessment and decision-making skills
- Passion for excellent customer service and customer experience
- Demonstrates strong critical thinking, problem-solving, and self-directed skills.
- Excellent interpersonal communication, and presentation skills with a diverse group of stakeholders (hospital partners, front-line staff, management team)
- Effective time management skills, with the ability to work independently and co-operatively in a busy multidisciplinary environment in various settings (e.g. at the hospital, in the office, in the community).
- Advanced skills in Microsoft Office (Word, Excel, PPT, Visio) and comfort with learning/working with new and emerging technologies (e.g. remote patient monitoring/virtual care technologies,

  • Transitions Care Lead

    3 weeks ago

    North York, Canada Saint Elizabeth Health Care Full time

    About the Role An exciting leadership role within hospital transitional programs working with closely with hospitals to transition and reintegrate clients back into the community. As a member of the Acute Transitions leadership team, you are passionate about informing and shaping the transition from hospital to home and being at the forefront of healthcare...

  • Transitions Care Lead

    4 weeks ago

    York, Canada SE Health Full time

    **About the Role** An exciting leadership role within hospital transitional programs working with closely with hospitals to transition and reintegrate clients back into the community. As a member of the Acute Transitions leadership team, you are passionate about informing and shaping the transition from hospital to home and being at the forefront of...

  • Transitions Care Lead

    5 months ago

    York, Canada SE Health Full time

    **About the Role** An exciting leadership role within hospital transitional programs working with closely with hospitals to transition and reintegrate clients back into the community. As a member of the Acute Transitions leadership team, you are passionate about informing and shaping the transition from hospital to home and being at the forefront of...

  • Transitions Care Lead

    5 months ago

    York, Canada SE Health Full time

    **About the Role** An exciting leadership role within hospital transitional programs working with closely with hospitals to transition and reintegrate clients back into the community. As a member of the Acute Transitions leadership team, you are passionate about informing and shaping the transition from hospital to home and being at the forefront of...

  • Office Administrative Assistant

    4 months ago

    North York, Canada Elder Care Transitions Inc. Full time

    **About us** Elder Care Transitions Inc. is a small business in Toronto. We are professional, customer-centric, excellence driven, and our goal is to provide an environment where our employees can grow interpersonal skills while working together as a team to achieve our common goals. Our work environment includes: - Modern office setting - Kitchen /...

  • Mover/driver

    4 months ago

    North York, Canada Elder Care Transitions Inc. Full time

    _Mover and Driver _ We are a fast growing business that caters to Seniors who are in transition. We assist in downsizing, moving, decluttering, and creating a new home-like environment for them in their new Residence. Our team is looking for professional movers, those who have experience with driving & loading trucks professionally is a bonus! Join us in...

  • Mover/driver

    5 months ago

    North York, Canada Elder Care Transitions Inc Full time

    **Mover Duties and Responsibilities** **Pack and Prepare Items** At the destination, movers help prepare and pack customers’ items to prevent damage during transit. Their tasks include disassembling furniture, wrapping items in bubble wrap or cellophane wrap, putting loose items in boxes and sealed bags, and using straps and moving blankets on larger...

  • Brand Manager

    5 months ago

    North York, Canada Elder Care Transitions Inc. Full time

    **Job Description: Brand Manager** **Position Overview**: The Brand Manager plays a pivotal role in developing and implementing strategies to enhance the perception and visibility of the company's brand. This position requires a creative thinker with strong leadership skills and a deep understanding of branding principles. **Key Responsibilities**: -...

  • Personal Support Worker

    5 months ago

    North York, Canada Bayshore HealthCare Full time

    **Make “being the difference” your Career. **.** Bayshore is looking for passionate and caring **Full-Time** **Personal Support Workers** to join our amazing team at our **Greystone Transitional Care Unit** located in **Ottawa**. Full-Time position in an inpatient setting (Transitional Care Unit) with 12-hour shifts and rotation of day and night shifts...

  • Packing Specialist

    5 months ago

    North York, Canada Elder Care Transitions Inc Full time

    Responsibilities: 1. Safely and efficiently pack and unpack belongings for elderly clients during the moving process. 2. Handle fragile items with care, ensuring they are properly wrapped and secured to prevent damage. 3. Organize and label boxes according to a systematic approach for easy identification during unpacking. 4. Collaborate with the moving...

  • Personal Support Worker

    5 months ago

    North York, Canada Bayshore HealthCare Full time

    **Make “being the difference” your Career. **.** Bayshore is looking for passionate and caring **Personal Support Workers** to join our amazing team at our amazing Transitional Care Unit located in North York. You will be creating special moments for clients each and every day. If your calling is to be the “difference” by providing outstanding care,...

  • Crosslinx Transit Soluations

    5 months ago

    North York, Canada Paladin Security Full time

    Crosslinx Transit Soluations - Mobile - Full Time - Nights Site Description: Crosslinx Transit Solutions (CTS) is a design and construction consortium comprised of four different transportation infrastructures: ACS-Dragados, Aecon, EllisDon and SNC-Lavalin. CTS works with these four partners to design, construct, and finance a transit system consisting of...

  • Clinical Transitions Manager

    6 months ago

    York, Canada SE Health Full time

    **Clinical Transitions Manager** **Hybrid Position - covering Western York Region and North York** This is an exciting SE Health role providing clinical and operational leadership to hospital to home transitions programs and coaching self-directed interdisciplinary teams who will be providing holistic care to clients in the community. As a member of the...

  • Care Coordinator

    5 months ago

    North York, Canada Home and Community Care Support Services Full time

    **Job Description**: - Are you an experienced registered nurse (BScN), physiotherapist, occupational therapist, social worker, or speech language pathologist seeking a rewarding career that cares for others, in a professional practice that cares for you? You’re looking in the right place.As a - **Ca** **re Coordinator**, you will assess and determine...

  • Behavioural Support Manager

    4 months ago

    North York, Canada Hawthorne Place Care Centre Full time

    Do you have a passion for making a difference? Making every moment matter is about improving all the things that make life enjoyable. Things like making someone feel better, making connections with them or for them with other residents, showing them a new song or even just giving them something to look forward to. At Hawthorne Place Care Centre, we are...

  • Behavioural Support Manager

    4 months ago

    North York, Canada Hawthorne Place Care Centre Full time

    Do you have a passion for making a difference? Making every moment matter is about improving all the things that make life enjoyable. Things like making someone feel better, making connections with them or for them with other residents, showing them a new song or even just giving them something to look forward to. At Hawthorne Place Care Centre, we are...

  • Housekeeper - Transitional Care Unit

    5 months ago

    North York, Canada Bayshore HealthCare Full time

    Make “being the difference” your Career.. Bayshore is looking for professional Housekeeper to join our amazing team. You will be attending to our facilities with integrity and attention to detail each and every day. - If your calling is to be the “difference” by providing outstanding services, than a Career with Bayshore is the Perfect Fit for YOU! -...

  • Director of Care

    5 months ago

    North York, Canada Hawthrone Park Care Centre Full time

    Are you an individual that has a passion for making a difference? At the Hawthorne Place Care Centre, we are passionate about providing compassionate care for families loved ones, where the residents of our home come before anything else. Our values follow a ‘People’ focused philosophy, Participation ~ Excellence ~ Openness ~ Performance ~ Longevity ~...

  • Transitional Care Assistant

    4 weeks ago

    North Bay, Canada Canadian Red Cross Full time

    **Employee Working Location**: In-Person (North Bay, ON) **Employment Status**: Casual **Salary band **:$ 20.00 / hour The Canadian Red Cross (CRC) - an inspirational not for profit organization, helps people and communities in Canada and around the world in times of need and supports them in strengthening their resilience. As a **Canada’s Best...

  • Transition Nurse

    1 month ago

    North Vancouver, Canada Vancouver Coastal Health Full time

    Salary The salary range for this position is CAD $41.42/Hr. - CAD $55.91/Hr. Job Summary Come work as a Transition Nurse with Vancouver Coastal Health (VCH)! Vancouver Coastal Health is looking for a Registered Nurse to join the Transition Services team at Lions Gate Hospital in North Vancouver, BC. Apply today to join our team! As a...