Care Transition Coordinator
1 month ago
Job Summary
The Transition Navigator is a key member of the interprofessional team at Michael Garron Hospital, providing comprehensive, patient-centered transition planning for patients from hospital to the next destination of care. With a focus on excellence throughout the transition process, the Transition Navigator builds collaborative relationships and strives to deliver an exceptional patient/family experience through the healthcare journey.
Key Responsibilities
- Develop a plan for a transition out of hospital that considers the needs of the patient from a cultural, financial, social, and spiritual perspective.
- Work toward a seamless and sustainable transition, utilizing knowledge and understanding of community resources, legislation as it relates to Alternative Level of Care (ALC), Substitute Decision Makers Act, Public Guardian and Trustee, and the Public Hospitals Act to reduce patient length of stay and readmissions rates.
- Provide education and use teach-back methodology to ensure health literacy is embedded into the transition process, with follow-up discharge phone calls at regular intervals, to ensure a smooth discharge.
- Collaborate with the interprofessional team to ensure a comprehensive and patient-centered approach to care.
Requirements
- Bachelor's degree in a healthcare field.
- Registration in good standing with relevant professional college.
- 2-3 years recent experience in hospital-based acute care, in a professional field required.
- 2 years recent experience in transition/discharge planning required.
- Working knowledge of community resources, LHIN Home and Community Care, long-term care facilities, rehabilitation, and palliative care facilities/programs required.
- Experience working with the geriatric population and medical/surgical patients required.
- Demonstrated knowledge and skills in transition/discharge planning, conflict resolution, and creative problem-solving required.
- Demonstrated working knowledge of legislation including the Substitute Decision Makers Act, Alternative Level of Care, Public Hospitals Act.
- Experience working with the Resource Matching and Referral system and electronic documentation systems.
- Demonstrated ability to prioritize multiple competing workload demands.
- Superior communication and negotiation skills.
- Demonstrated ability to provide resource identification, referral, and linking.
- Demonstrated ability to work collaboratively as a member of an interprofessional team.
- Demonstrated ability to build relationships with internal and external partners.
- Demonstrated ability to prioritize and work effectively in a fast-paced environment required.
- Demonstrated patient-centered philosophy of care provision.
- Good work and attendance record required.
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