Transitions Care Lead

3 weeks ago

Greater Toronto Area, 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 healthcare innovation in Canada.

Hybrid role (virtual /in-person) covering the GTA

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.

**Main 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 in-home transition services
- Participate in hospital discharge care conference 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
- 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 programs support
- Other duties to ensure program is running smoothly

**Requirements**:

- 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 or 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, EHR systems, reporting systems)
- A valid driver’s license and access to a reliable vehicle.

**About SE Health**

At SE, we love what we do. Every day, we bring hope and happiness to clients, homes, and communities across Canada. We treat each person with dignity and love, like our own family; we build empathy; and we do the right thing. We are always inspired to make a difference. As a not-for-profit social enterprise, we share knowledge, provide the best care, and help each client to realize their most meaningful goals for health and wellbeing. We are an inclusive workplace offering competitive pay, benefits, pension, and work life balance. We’re a great place to work, and we hope you’ll join our team.

Please note that due to the unprecedented circumstance of the Global Pandemic and the resultant public health crisis; and in the interest of the health and safety of our patients/clients, employees, and greater good of public health, **SE Health requires those that wish to work for this organization to be fully vaccinated against COVID-19.** Fully vaccinated means a person has received both doses of the COVID-19 vaccine and it has been 14 days since the last dose

  • 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...

  • 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 & Transitions Facilitator Gim

    1 month ago

    Toronto, Canada Unity Health Toronto Full time

    The 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 - Hlv Program

    7 days ago

    Toronto, Canada St. Michael's Hospital Full time

    The 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...

  • Care & Transitions Facilitator, General Internal

    1 month ago

    Toronto, Canada St. Michael's Hospital Full time

    The 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...

  • Lead Climbing Arborist

    4 weeks ago

    Greater Toronto Area, Canada Central Tree Care Full time

    Lead Climbing Arborist *Immediate Employment Available* Since 1996, we have cared for Toronto’s urban forest, and we take pride in providing prompt and reliable service to our clients. We are a full-service tree care company and are seeking enthusiastic individuals to join our team. Position Overview The Lead Climbing Arborist directs the climbing...

  • Care & Transitions Facilitator Trauma & Neurosurgery

    1 week ago

    Toronto, Ontario, Canada St Michael's hospital Full time

    Care & 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...

  • Rail and Transit Discipline Lead

    1 month ago

    Toronto, Canada IBI Group Full time

    **Company Description** Arcadis is the world's leading company delivering sustainable design, engineering, and consultancy solutions for natural and built assets. We are more than 36,000 people, in over 70 countries, dedicated to improving quality of life. Everyone has an important role to play. With the power of many curious minds, together we can solve...

  • Transition Coordinator

    1 month ago

    Toronto, Canada Holland Bloorview Kids Rehabilitation Hospital Full time

    The 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,...

  • Rail and Transit Discipline Lead

    4 days ago

    Toronto, Canada IBI Group Full time

    Rail and Transit Discipline Lead Full-time Company Description Arcadis is the world's leading company delivering sustainable design, engineering, and consultancy solutions for natural and built assets. We are more than 36,000 people, in over 70 countries, dedicated to improving quality of life. Everyone has an important role to play. With the...

  • Critical Care Resource Lead

    1 day ago

    Toronto, Canada Salvation Army Toronto Grace Health Care Centre Full time

    **TORONTO GRACE HEALTH CENTRE: JOIN OUR TEAM!** The Toronto Grace Health Centre (TGHC) provides specialized care and services to those individuals who require Complex Continuing Care, Post Acute Care Rehabilitation, Palliative Care, and Transitional Care. The care and services provided at TGHC help facilitate the patient flow through the health care system...

  • Care & Transitions Facilitator - Gen. Surg/gastro

    1 month ago

    Toronto, Canada St. Michael's Hospital Full time

    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. In this role, you will be supporting **16CN (GI/General Surgery/Plastics) and 8PGT (Hematology/Oncology)** Inpatient Units. As...

  • Care & Transitions Facilitator Trauma & Neurosurgery

    2 weeks ago

    Toronto, Canada St Michael's hospital Full time

    Care & 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...

  • Care & Transitions Facilitator - Cath Lab (Perm Ft)

    4 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...

  • Customer Care Associate

    1 week ago

    Greater Toronto Area, Canada Precise ParkLink Inc. Full time

    **Company Description**: As Canada's parking industry leader for 30 years, our expertise in providing full-service parking solutions has evolved into urban mobility intelligence. We now innovate and support solutions required for all modes of transportation including public transit, parking, and electric car charging stations. **Job Summary**: The Customer...

  • Transition Planner

    1 month ago

    Toronto, Ontario, Canada St Michael's hospital Full time

    Transition Planner - Emergency Department (Job ID: 4395)Unity Health Toronto, comprised of Providence Healthcare, St. Joseph's Health Centre and St. Michael's Hospital, works to advance the health of everyone in our urban communities and beyond. Our health network serves patients, residents and clients across the full spectrum of care, spanning primary care,...

  • Transition Navigator

    1 month ago

    Toronto, Canada Michael Garron Hospital Full time

    Overview 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 time

    Overview 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...

  • Planning Lead

    17 hours ago

    Greater Toronto Area, Canada Webuild Full time

    About WebuildWebuild is an international construction company of civil engineering pioneers who have been at the forefront of the construction business for almost a century now. We are looking for an experienced Planning Lead to join a growing team in our Toronto office for the Ontario Line / RSSOM project. You will be part of the Connect 6ix team, that is...

  • 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...