Patient Flow Navigator

**Company Biography**

Orillia Soldiers’ Memorial Hospital (OSMH) is located in the City of Orillia - a beautiful community nestled along the shores of Lake Simcoe and Lake Couchiching. Orillia offers an environment where a health work/life balance is easy to achieve as exceptional urban amenities, natural resources, points of interest, and recreational opportunities abound.

People have always been OSMH’s greatest strength. Our committed team has helped our community for over a century. We offer an environment where each individual works interdependently towards common goals: we value _Trust, Courage and Teamwork_. We are an organization where individuals’ contributions are valued and there are many opportunities for personal growth and development.

**Position Summary**

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The Patient Navigator promotes optimal patient and clinical outcomes by assessing and facilitating effective quality of care, utilization of resources and length of stay in acute care, complex continuing care as well as the Emergency department. The Patient Navigator will identify and initiate complex discharge or transition plans for high risk patients (including regional renal in patients) and collaborate with physicians, interprofessional teams and appropriate community partners and resources to support Home First philosophy and practices, Significant to this role is case management expertise and complex discharge planning activities. Within the acute care in-patient areas, this individual identifies and addresses clinical care processes and/or other issues impeding the flow of patient care from admission to discharge, when working in the Emergency department the patient navigator supports and enhances the flow of patients through the department identifying and facilitating hospital admission avoidance cases and supporting transition to admission or other discharge destination. There is a focus on frail seniors who are at risk of suffering adverse events, loss of independence and admission to hospital.

Patient navigation within Acute Care and the Emergency Department requires knowledge and understanding of quality improvement processes and OSMH performance metrics. It is expected this position will be assigned to provide patient navigation and complex case management/discharge planning in the acute in patient areas and the Emergency department, assignments will depend on needs of the Hospital.

PRIMARY RESPONSIBILITIES:

- Contribute to assessment of patient’s medical, functional, cultural, and psychosocial needs, family issues/dynamics, extent of community resources in light of input/assessments from the multidisciplinary team and community partners re: identified needs and care options to facilitate transition through care continuum
- Provide ongoing re-evaluation of discharge plan especially if other special needs identified, e.g. significant behavioral/psychiatric concerns. Provide consultation and coordination of legal/financial capacity or SDM issues including potential PGT involvement. Facilitate interdepartmental, inter-hospital and interprofessional communication amongst the team with patients and families.
- Demonstrated excellence in interview skills, coordinate and lead family meetings in support of transitions and facilitation of program referrals
- In collaboration with the health care team, facilitate and coordinate appropriate consultations, treatments, tests and procedures to expedite completion within a recommended timeline.
- In collaboration with the health care team, information technology and decision support department, review and validate statistical data from UMS, RFD, EDD, LOS on a daily basis and implement and document plan of care changes as appropriate.
- Maintain an in depth knowledge of community resources, facilitate partnerships through daily interface and collaboration with our community partners such as Community Care Access Centre (CCAC), community agencies, retirement homes and Long-Term Care Homes.
- Advocate for ALC designation when acute medical treatment is completed and complete appropriate documentation.
- Attend, participate and/or lead ALC rounds, Daily Bed Meeting, Weekly program Huddles, and hospital/community committee work
- Acts as resource and leader
- Participate, facilitate and support corporate patient flow and quality improvement initiatives.
- Other duties as assigned by program manager

In Patient Responsibilities
- Develop concise case summaries, present cases to Joint Discharge Operations Committee and at ALC rounds
- Collaborate and partner with Regional renal program team members including social workers, team lead, nephrologists to support discharge and transition plans for the regional renal patients
- Attend weekly renal rounds

ED Responsibilities
- Review all potential patients considered for admission, and those at high risk for admission, in collaboration with the interprofessional team explore appropriate alternatives to admission.
- Collaborate with the ED