Healthcare Transition Coordinator

4 weeks ago

Toronto, Ontario, Canada Michael Garron Hospital Full time

About the Role

The Transition Navigator is a key member of the interprofessional team at Michael Garron Hospital, responsible for providing comprehensive, patient-centered transition planning for patients from hospital to the next destination of care. This role requires a strong focus on delivering 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.
  • Collaborate with the interprofessional team to ensure a seamless and sustainable transition.
  • Utilize knowledge and understanding of community resources, legislation, and healthcare systems 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.
  • Follow-up discharge phone calls at regular intervals to ensure a smooth discharge.

Requirements

  • Bachelor's degree in a healthcare field.
  • Registration in good standing with a 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, and 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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