916066 Care & Transitions Facilitator - General
1 month ago
The Care & Transitions Facilitator is a practitioner in the Specialized Complex Care (SCC) program that is results oriented and 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 inpatient cases. Working collaboratively with interdisciplinary teams, you will be responsible for facilitating the patient journey from admission to discharge through assessment, care planning, transitions and evaluation of care for the patient population. A key component of the role is utilization management related to daily patient access and flow.
Other duties include:
- Educating patients/families, students, Residents and new staff;
- Coordinating multiple referrals;
- Networking and building community and internal partnerships;
- Identifying and leading unit based quality initiatives.
**RESPONSIBILITIES**:
- Care Facilitation:_
- Assess the needs of patients and families working to advance all patient journeys in order to reduce delays in service/disposition
- 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 and rehab services
- Advocate for patient services needed for a safe and effective discharge/transition
- Negotiate with reluctant or challenging patients for limited services or space
- Identify patient care/safety issues working to resolve issues and communicate concerns to the unit Clinical Leader Manager (CLM)
- Circulate daily through unit, communicating and collaborating about patient care needs/goals with support service teams to ensure optimized clinical process efficiencies and patient transitions
- Utilize expert knowledge and leverage external resources to reduce system barriers and facilitate safe and timely discharges as required
- 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 access, flow, and transitions in care
- Education:_
- 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 bedside nurses’ active involvement in patient care plan and discharge activities
- Collaborate with CLM to engage staff to reach consensus related to care by providing direct or indirect assistance, guidance or supervision along the continuum of care
- Provide orientation related to patient flow on the unit/organization e.g. BED, ELOS, ALC
- 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
- Facilitate a multidisciplinary approach to quality and cost-effective complex patient care in the acute setting
- Offer strategic counsel to program leaders and unit staff to assist in prioritizing care issues related to patient flow, utilization and staffing as well as system issues/barriers through analysis of core metrics such as, but not limited to: ALOS, BELOS, Ambulatory volumes
- Monitor patient flow to analyze throughput and hospital wide demand and capacity status
- Identify/analyze care practices & system processes that contribute to/impede outcomes and make recommendations related to evaluation and redesigning processes
- Administrative:_
- Participate/lead daily interdisciplinary rounds
- Develop care management tools (assist in development of care maps/patient protocols for high volume procedures/diagnosis)
- Engage After-hours Clinical Managers and / or CLM in any situations that may need support beyond day shift
- Participate in internal and external committees/working groups
- Performs cross functional and other duties as assigned and/or requested
**QUALIFICATIONS**:
- Regulated Health Professional with a Bachelor of Science Degree in Nursing/Health Discipline required
- Registration in good standing with a regulatory college is required
- Master's degree would be considered an asset
- Current and advanced clinical assessment skills related to the needs of the program are required in the area of Surgical/GI/Plastics
- Demonstrated ability in problem solving
- Proven success in generating ideas fo
-
Care & Transitions Facilitator, General Internal
1 month ago
Toronto, Canada St. Michael's Hospital Full timeThe Care & Transitions Facilitator is a practitioner in the General Internal Medicine program that is results oriented and 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 inpatient cases. Working...
-
Care & Transitions Facilitator Gim
1 month ago
Toronto, Canada Unity Health Toronto Full timeThe Care & Transitions Facilitator is a practitioner in the General Internal Medicine program that is results oriented and 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 inpatient cases. Working...
-
Care & Transitions Facilitator, Pediatric Clinic
1 month ago
Toronto, Canada St Michael's hospital Full time**Care & Transitions Facilitator, Pediatric Clinic (Job ID**: 3946) **RESPONSIBILITIES**: The primary responsibilities of the Compass Clinic Care & Transitions Facilitator includes: Completing an initial assessment to determine the needs of the patients and families Supporting care coordination and connecting to resources Employing active listening and...
-
Toronto, Ontario, Canada St Michael's hospital Full timeCare & Transitions Facilitator Trauma & Neurosurgery (Job ID: 4665) Posting Description The Care & Transitions Facilitator is a practitioner in the Trauma Neurosurgery program that is results oriented and 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...
-
Toronto, Canada St Michael's hospital Full timeCare & Transitions Facilitator Trauma & Neurosurgery (Job ID: 4665) Posting Description The Care & Transitions Facilitator is a practitioner in the Trauma Neurosurgery program that is results oriented and committed to enhance the quality of patient care within a complex health, social and fiscal environment. As a clinical expert, you will be instrumental...
-
Transitional Care Manager
4 weeks ago
Toronto, Canada SPRINT Senior Care Full time**Supervisor, Transitional Care** **About SPRINT Senior Care**: We began caring for seniors and enabling seniors to care for themselves in 1983. We continue to do so today as an accredited, not-for-profit community support service agency in Toronto by offering a wide range of practical and low-cost services to seniors and their caregivers. Our services help...
-
Toronto, Canada St. Michael's Hospital Full timeThe Care & Transitions Facilitator is a practitioner in the Specialized Complex Care (SCC) program that is results oriented and committed to enhance the quality of patient care within a complex health, social and fiscal environment. In this role, you will be supporting **16CN (GI/General Surgery/Plastics) and 8PGT (Hematology/Oncology)** Inpatient Units. As...
-
Care & Transitions Facilitator - Hlv Program
7 days ago
Toronto, Canada St. Michael's Hospital Full timeThe Care & Transitions Facilitator is a practitioner in the Heart Lung and Vascular program that is results oriented committed to enhance the quality of patient care within the Schroeder Brain & Heart Institute - a complex health, social and fiscal environment. As a clinical expert, you will be instrumental in coordinating the use of clinical resources for...
-
Coordinator, Integrated Transitions
1 month ago
Toronto, Canada North York General Hospital Full timeCompany 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...
-
Toronto, Canada St. Michael's Hospital Full timeThe 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...
-
Toronto, Canada St. Michael's Hospital Full timeThe Kidney Transplant Team is looking for a Care and Transitions Facilitator (CTF) that thrives within a changing environment and works well with the inter-professional team to advocate for and promote wellness while ensuring the delivery of exceptional client care. The CTF is a practitioner, working within the team that is results-oriented and committed to...
-
Coordinator Transitional Care
7 days ago
Toronto, Canada SickKids Full time**About SickKids**: Dedicated exclusively to children and their families, The Hospital for Sick Children (SickKids) is one of the largest and most respected paediatric healthcare centres in the world. As innovators in child health, we lead and partner to improve the health of children through the integration of healthcare, leading-edge research and...
-
Care Coordinator, Nygh@home
4 weeks ago
Toronto, Canada North York General Hospital Full timeCompany 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...
-
Transition Coordinator
1 month ago
Toronto, Canada Holland Bloorview Kids Rehabilitation Hospital Full timeThe 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,...
-
Discharge & Flow Coordinator (Transitional
1 week ago
Toronto, Canada University Health Network Full timeContract - Department: Other (Not Listed) **Company Description**: - 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. The breadth of research,...
-
Transition Navigator
1 month ago
Toronto, Canada Michael Garron Hospital Full timeOverview The Transition Navigator provides comprehensive, patient-centered transition planning for patients from hospital to the next destination of care. The Transition Navigator is a key member of the interprofessional team. With a focus on the provision of excellence throughout the transition process, the Transition Navigator builds collaborative...
-
Transition Navigator
1 month ago
Toronto, Canada Michael Garron Hospital Full timeOverview The Transition Navigator provides comprehensive, patient-centered transition planning for patients from hospital to the next destination of care. The Transition Navigator is a key member of the interprofessional team. With a focus on the provision of excellence throughout the transition process, the Transition Navigator builds collaborative...
-
Patient Care Coordinator
3 weeks ago
Toronto, Canada Salvation Army Toronto Grace Health Care Centre Full time**TORONTO GRACE HEALTH CENTRE** **Join our Team!** **We are actively recruiting for** **Patient Care Coordinator** **Full Time** **Harbour Lights** The Salvation Army Toronto Grace Health Centre (TGHC) is a mission of The Salvation Army that provides specialized and integrated care and services to individuals with multifaceted chronic or persistent...
-
Employment Facilitator
1 week ago
Toronto, Canada Jake's House Full time**Title**: Employment Facilitator **Type**: 2-month Contract - contract in collaboration with Canada Summer Jobs. Possibility of extension **Reports**: Associate Director, Employment Training Program **# of positions**: 3 **Location(s)**: Etobicoke **Industry**: Not-for-profit **Salary**: $18/ hour **COMPANY PROFILE** Founded in 2004, Jake’s House...
-
Clinical Coordinator, General
4 weeks ago
Toronto, Canada North York General Hospital Full timeCompany 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...
