Transitional Care Coordinator Remote Care

1 month ago

Toronto, Canada The Salvation Army - Toronto Grace Health Centre Full time

TORONTO GRACE HEALTH CENTRE

Join our Team

We are actively recruiting for

Transitional Care Coordinator

Permanent Full Time

The Toronto Grace Health Centre (TGHC) provides, specialized care to those individuals who require Complex Continuing Care, Post-Acute Care Rehabilitation, Transitional Care, and Palliative Care services. The care and services provided at TGHC help facilitate the patient flow through the health care system and ensures recovery to those individuals who may return to their homes or to Long Term Care (LTC) facilities in their communities. TGHC operates in 3 sites - the Main site (Church & Bloor St) and our Harbour Lights site and Specialized Care Centre (Victoria Park & McNicoll). Our organization is committed to collaborating with patients and families in their journey through the health care system, effectively supporting their integration back into the community.

As a compassionate, caring, and influential member of the interprofessional team, you will make a personal difference in the quality of life of our patients, residents, and families. If you want to work in an environment where every face is familiar and where care, compassion, and commitment flow to the persons that we serve as well as the staff, join our team and become part of an amazing team with the Toronto Grace family.

**Position Summary**:
Reporting to the Manager - Remote Care Monitoring & Assess and Restore, the Transitional Care Coordinator (TCC) is a critical member of the Remote Care Monitoring/Remote Care Monitoring+ (RCM/RCM+) program. Once RCM+ clients are discharged from hospital settings, the transitional care coordinator is the primary contact for patients, essential care partners (e.g. HCCSS, PSW agencies, etc.) and the clinical team, ensuring a smooth transition post-discharge. RCM+ clients are referred from locations across Toronto and beyond, with service available across Ontario. The TCC provides leadership for the client experience by working closely to create one care team to deliver exceptional care. Working closely with the RCM+ interdisciplinary team, this role focuses on providing comprehensive care to support a clients' overall health and well-being; including patient-centered navigation, case management, and coordination of services to patients as they access care within Toronto Grace Health Centre and with partner organizations.

**Responsibilities**:

- Acting as the key lead liaising between clients, the Remote Care Monitoring (RCM) team, community providers, primary care providers, and other providers, to ensure all components of a client's care are provided.
- Developing, supporting and overseeing a client's care path through the various care settings to ensure continuity of care.
- Supporting the RCM Manager with overseeing partnership operations between Toronto Grace Health Centre RCM and hospital partners.
- 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.
- Leading ongoing innovation and optimization efforts

**Qualifications**:

- Undergraduate/Graduate degree in a related allied health profession such as Physiotherapy, Occupational Therapy, Social Work, etc. Current membership in good standing with applicable/relevant regulatory health professional body in Ontario is required.
- Two (2) years of clinical experience required - experiences in both community health settings and acute care preferred
- 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 ability to quickly respond to patients and situations with resourcefulness, flexibility and adaptability is required.
- Excellent interpersonal, communication, organizational and decision-making skills required.
- Demonstrated leadership skills, including problem solving, critical thinking, and conflict resolution
- Demonstrated ability to work both independently and collaboratively with an interdisciplinary team, family members, support networks, and a variety of formal and informal service providers
- Demonstrated cultural sensitivity awareness and skills to inform and best plan and facilitate coordination of patient care.
- Excellent time management and stress management skills are required.
- Computer literacy and basic proficiency is required with a demonstrated willingness to learn and adapt to new technology.
- Fluency in English (verbal and written) is required.
- Self-motivated, team player, and ability to thrive in

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