Scope/ltc+ Navigator

Position Profile:
**Build your career at the hospital that’s building for the future**

Humber River Hospital is committed to revolutionizing patient care for our diverse community. We’re looking for exceptional individuals to join our great team: people who share our passion to deliver excellent, patient-focused, expert care. The Hospital is formally affiliated with both the University of Toronto and Queen’s University.

We have an exciting opportunity for a **Full Time SCOPE/LTC+ Navigator** to join our team within **Integrated Health Systems & Partnerships** at Humber River Hospital. This department works collaboratively with internal departments, community partners, primary care, agencies, Ontario Health and the Ministry of Health to plan and build an Integrated Health System to improve the health of our community. SCOPE (Seamless Care Optimization the Patient Experience) is a quality improvement collaboration between the hospital and primary care providers (PCPs) located in North West Toronto. The SCOPE service is a virtual inter-professional team that facilitates greater access to hospital-based interdisciplinary resources and other specialists care. SCOPEaims to reduce avoidable ED visits and hospital re-admissions for patients in need. LTC+ (Long Term Care +) is a virtual care model that provides direct access to a suite of services including real-time access to virtual GIM consultations, specialist care and community resources for the partner LTC homes in North West Toronto. LTC+ aims to deliver the best care possible to residents in LTC homes to avoid unnecessary transfers to hospital and improve access to outpatient clinics/resources.

**Reporting to the Manager, Family Medicine Teaching Unit and Integrated Care Services **, the SCOPE/LTC+ Navigator will coordinate and assist physicians in primary care and in Long Term Care Homes in navigating SCOPEservices, providing centralized access to hospital and community services, with follow-up on status of referrals, results, and consults. This role supports timely access, ensures navigator to appropriate resources, and reduced ED visits as patients are proactively connected to the right level of care

**Union**: Non Union

**RESPONSIBLITIES**
- Play a leadership role in the implementation, monitoring, and evaluation of the SCOPE and LTC+ program
- Participate in the implementation, monitoring, and evaluation of the SCOPE/LTC+ program
- Participates in internal and external committees/working groups
- Enhance work-flow and communication pathways between hospital, primary care and community care by identifying barriers to care and work towards creating new care pathways to promote and optimize seamless care for the client.
- Advocate for, and contribute to, the establishment of organizational structures and resources to support the growth of SCOPE and LTC+ in keeping with the direction and priorities of the organization
- Advocate to identify gaps in services, needed for individualized program consideration and system level changes required to meet changing needs of the patient population
- Develop and foster links with external partners to facilitate continuity of patient care; including community outreach
- Assist Primary Care Providers in the community and LTC with system navigation, referrals to specialists, and resources in the community, and other appropriate community, clinical and specialized supports to address patient health concerns.
- Ensure seamless navigation of existing services; triage and forward referrals to appropriate SCOPE/LTC+ contact (i.e. Internist, Home and Community Care Coordinator, Imaging, Outpatient Clinics)
- Collaborate with the health care team to improve patient care as they transition through the health care system
- Collect relevant patient information required for assessment and database entry (Patient Name, DOB, HC#)
- Understand and clarify PCP primary concerns and request for support
- Work collaboratively and in relationship with the inter-professional team while role modelling relationship centered care
- Use concepts from complexity thinking and relational inquiry when in relationship with others.
- Collect Data for research evaluation for each referral - Database Entry forms to be completed with each referral and submitted to the evaluation team on a weekly basis
- Review available/relevant information from Meditech (EMR) to determine assessment and care planning
- If client is an existing or former clinic patient, will re-connect with staff to communicate PCP concerns and request for assessment
- This includes the clarification of referral criteria and identification of the resource that will best suit the health care need
- Improve communication and collaboration between consultants and primary care services by assisting PCP staff in the compilation of referral packages and follow-up of referrals
- Provide PCP or PCP staff with clinic/referral information
- Navigate hospital clinics and resources that w