Transition Coordinator

6 months 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, client centered seamless transition plan.

The transition coordinator provides system navigation for clients and families as they move from acute care services to rehab services and then as they integrate into the community and-or home. Clients may range from birth to 18 years of age with a variety of medically complex conditions including brain injury, spinal cord injury, orthopaedic surgery and other developmental conditions which require medical technology.

The transition coordinator utilizes their knowledge and understanding of health care system and community resources to enhance operational effectiveness of the inpatient units and day program while supporting seamless and safe transitions. They are strength based and solution focused in their approach to community integration. The transition coordinator provides education on the transition process and community services to clients, families and teams to ensure a safe transition for each client and family.

**Key Responsibilities**

**Clinical Practice**:
Assesses the transition needs and goals of the client and family in partnership with the team

Coordinates smooth and seamless transitions for clients and families between and across services

Develops a timely, effective and safe transition plan in collaboration with clients, families and interdisciplinary teams

Provides case management and care coordination activities as appropriate

Documents transition plan and activities

Communicates effectively with clients and families and members of the interprofessional health care team

Participates in and/or leads complex admission and transition planning processes

Participates in systems improvement and innovations to ensure access and efficient use of clinical transition services

**Interprofessional Collaborations**:
Collaborates with interprofessional team members, clients and families as well as community healthcare providers and agencies to achieve seamless transitions

Participates in quality improvement initiatives and committees

Collaborates and participates in planning, promoting, implementing and evaluating new ideas, concepts, and interventions to facilitate transition for clients and families

Provides support and expertise to health care team on transitions and community resources

Builds collaborative relationships with key partners (e.g. SickKids, Home & Community Care Services, and other referring partners)

**Leadership**:
The transition coordinator will use strength based leadership to develop themselves and engage others, build partnerships and networks to achieve results, and use systems/critical thinking to champion and orchestrate change.

Provides leadership in the area of transitions and is a resource person and role model for the interprofessional team

Guides, initiates and provides leadership to support operational effectiveness and client flow(e.g. LOS, wait times)

Participates in professional, program and hospital-wide initiatives

Actively promotes professional role through participation in external forums

Examines current processes, identifies opportunities for change and provides recommendations for improvements

**Research and Education**:
Uses evidence in practice, develops and uses clinical practice guidelines, pathways and protocols in transition planning and service delivery

Participates in quality improvement and research activities as required

Functions as a content expert and resource person in their specialized field of practice, and takes advantage of informal and formal learning opportunities to educate the interprofessional team

Educates clients, families, members of the health care team, referring facilities and other community providers

Enhances personal and professional development through reflective practice and by attending educational opportunities and /or conferences

**Qualifications**

**Education**

A Baccalaureate Degree or equivalency in health-related discipline, Master’s Degree preferred

Requires active registration as a Regulated Health Care Professional in Ontario

**Experience**

Minimum 3 years pediatric and experience working with families required

Experience working with children with disabilities and/or complex care needs and medical technologies preferred

**Skills**

Strong knowledge base related to current community resources

Excellent conceptual and theoretical understanding of evidence-based practice and ability to articulate the concepts as they relate to transitions

Demonstrated problem-solving and critical thinking skills using a strengths based and solution focused approach.

Effective communication and presentati

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