Transitions Care Lead

3 weeks ago

Niagara Falls, Ontario, Canada SE Health Full time
An exciting leadership role within hospital transitional programs working 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.

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.

Full time role - Remote opportunity

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
- Coordinate/Liaise with hospital navigator/coordinator and SE @home Team as required.
- 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
- Ensure all necessary referral documents (e.g. transition request form, medical orders, consult notes, allied health reports) and initial care plan instructions are received by SE @Home Team
- 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 program 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 of 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 Us:

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.

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.

SE Health is committed to the success of all its employees. If you feel you need accommodations because of illness or disability, please do not hesitate to contact the Talent Acquisition team at careers@sehc.com at your earliest convenience.

#J-18808-Ljbffr

  • Care Transition Specialist

    3 days ago

    Niagara Falls, Ontario, Canada Saint Elizabeth Health Care Full time

    Job Description:We are seeking a Care Transition Specialist to join our team at Saint Elizabeth Health Care. As a member of our interdisciplinary care team, you will provide comprehensive care to clients in their homes and communities.Your key responsibilities will include:Conducting client assessments and developing holistic care plansLeading care planning...

  • Care Transition Specialist Lead

    4 days ago

    Niagara Falls, Ontario, Canada SE Health Full time

    Care Transition Specialist Lead:This is an exciting opportunity to join our Acute Transitions team as a leader responsible for the smooth transition of clients from hospital to home.As a member of our leadership team, you will be accountable for providing exemplary leadership and care flow management between hospital partners and community care teams.Your...

  • Care Transitions Program Lead

    3 days ago

    Niagara Falls, Ontario, Canada SE Health Full time

    About the RoleThe Transitions Care Lead will be responsible for providing leadership and care flow management between hospital partners and community care teams. This exciting role involves ensuring excellence in client care, corporate/program objectives, and performance targets are met.Main responsibilities include acting as the primary point of contact for...

  • Transitions Care Director

    4 days ago

    Niagara Falls, Ontario, Canada SE Health Full time

    An exciting leadership role within hospital transitional programs working 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...

  • Healthcare Transition Specialist

    2 days ago

    Niagara Falls, Ontario, Canada Saint Elizabeth Health Care Full time

    About the Opportunity:We are seeking a highly skilled and experienced Healthcare Transition Specialist to join our team. In this role, you will be responsible for providing clinical practice leadership and coaching to interdisciplinary care teams, ensuring safe, effective, and efficient patient care.Your expertise in quality management, staff development,...

  • Clinical Transitions Manager

    1 week ago

    Niagara Falls, Ontario, Canada Saint Elizabeth Health Care Full time

    Clinical Transitions Manager Hybrid Position - Niagara and Hamilton This is an exciting SE Health role providing clinical and operational leadership to hospital to home transitions programs and coaching self-directed interdisciplinary teams who will be providing holistic care to clients in the community. As a member of the Acute Transitions leadership...

  • Healthcare Transition Specialist

    1 week ago

    Niagara Falls, Ontario, Canada Saint Elizabeth Health Care Full time

    About the Role:The Clinical Transitions Manager will provide clinical practice leadership and operational management to ensure the safe, effective, and efficient provision of care excellence to all clients and families.Key Responsibilities include providing clinical practice leadership, coaching and oversight management to interdisciplinary teams; managing,...

  • Home and Community Care Specialist

    1 week ago

    Niagara Falls, Ontario, Canada Saint Elizabeth Health Care Full time

    **About the Role:**We are looking for a highly skilled Home and Community Care Specialist to join our team at Saint Elizabeth Health Care. As a member of our care team, you will provide holistic care to clients in their homes and communities, working closely with other healthcare professionals to achieve optimal health outcomes.Responsibilities:Provision of...

  • Client-Centered Care Practitioner

    2 days ago

    Niagara Falls, Ontario, Canada Saint Elizabeth Health Care Full time

    Job Summary:We are seeking a highly skilled Client-Centered Care Practitioner to join our team at Saint Elizabeth Health Care. As a member of our interdisciplinary care team, you will provide client-centered care services to clients in their homes and communities.Key Responsibilities Include:Conducting client assessments and developing individualized care...

  • Transitions and Reintegration Specialist

    3 days ago

    Niagara Falls, Ontario, Canada SE Health Full time

    About the JobThe Transitions Care Lead will be responsible for providing leadership and care flow management between hospital partners and community care teams. This exciting role involves ensuring excellence in client care, corporate/program objectives, and performance targets are met.Main responsibilities include acting as the primary point of contact for...

  • Personal Care Assistant Lead

    1 week ago

    Niagara Falls, Ontario, Canada Saint Elizabeth Health Care Full time

    We are looking for a skilled and empathetic Personal Support Worker (PSW) to provide high-quality care to our clients in their own homes. As a PSW, you will work collaboratively with our multidisciplinary team to develop and implement personalized care plans.Job DescriptionAs a PSW, you will be responsible for providing direct client care, including personal...

  • Social Worker

    1 week ago

    Niagara Falls, Ontario, Canada Saint Elizabeth Health Care Full time

    looking to hire Social Workers to join our Transitions team - this is an exciting opportunity to be at the front-line of health care innovation in Canada. POSITION SUMMARY: We are seeking dynamic, passionate Social Workers who want to be part of the transformational change in home and community care by providing care in a truly client-centered...

  • Care Specialist

    3 days ago

    Niagara Falls, Ontario, Canada Saint Elizabeth Health Care Full time

    About the RoleWe are seeking a highly skilled and compassionate Care Specialist to join our team. As a Saint Elizabeth Health Care Speech Language Pathologist, you will have the opportunity to make a meaningful difference in the lives of our clients.The ideal candidate will possess excellent communication skills, be able to work effectively in a...

  • Community Health Care Manager

    3 days ago

    Niagara Falls, Ontario, Canada SE Health Full time

    About the CompanySE Health is a not-for-profit social enterprise committed to making a difference. Our mission is to provide exceptional care and services that meet the unique needs of our clients and their families.We value compassion, respect, and empathy in all aspects of our work. Our team is dedicated to delivering high-quality care and exceeding...

  • Community Rehabilitation Coordinator

    2 days ago

    Niagara Falls, Ontario, Canada Saint Elizabeth Health Care Full time

    About the Role:As a Community Rehabilitation Coordinator, you will play a vital role in supporting clients to achieve their health and wellbeing goals. You will work closely with our interdisciplinary care team to provide comprehensive care services in clients' homes and communities.Key Responsibilities Include:Providing comprehensive care services to...

  • Transitions Coordinating Nurse

    2 weeks ago

    Niagara Falls, Ontario, Canada JSSA Full time

    6123 Montrose Rd, North Bethesda, MD 20852, USA Req #616Thursday, March 6, 2025JSSA is looking for a full-time LPN to join our homecare/hospice team and provide support to our Transition program.Responsibilities:- Provide for the safe discharge of patients from hospice into community care settings.- Provide check-ins (in-person and telehealth) to recent...

  • Care Team Coordinator

    1 week ago

    Niagara Falls, Ontario, Canada Saint Elizabeth Health Care Full time

    **Job Description:**We are seeking a dynamic Care Team Coordinator to join our team at Saint Elizabeth Health Care. As a key member of our care team, you will be responsible for providing comprehensive care to clients in their homes and communities.Provision of client-centered care as part of an interdisciplinary teamPrimary contact for clients when...

  • Senior Care Assistant

    7 days ago

    Niagara Falls, Ontario, Canada Saint Elizabeth Health Care Full time

    Saint Elizabeth Health Care is a leading provider of healthcare services, dedicated to delivering high-quality care to clients in their own homes. As a Part-Time Personal Support Worker, you will play a vital role in supporting our clients' physical, emotional, and social well-being.You will work collaboratively with our interdisciplinary team to develop and...

  • Patient Care Coordinator

    7 days ago

    Niagara Falls, Ontario, Canada Saint Elizabeth Health Care Full time

    About SE Health:We are a not-for-profit social enterprise dedicated to delivering high-quality healthcare services across Canada.Our mission is to improve the health and wellbeing of our clients, while also supporting the development of our employees.We offer a comprehensive compensation package, including competitive salary, benefits, pension, and work-life...

  • Medical Center Transplant Team Lead

    1 day ago

    Niagara Falls, Ontario, Canada The Methodist Hospital Full time

    Job SummaryWe are seeking an experienced Nurse Practitioner to lead our Non-Acute Care Cardiology team at The Methodist Hospital. In this role, you will be responsible for providing expert care to patients with complex cardiac conditions, working closely with cardiologists and other specialists to develop effective treatment plans.Key responsibilities...