Transitions Care Lead

The Acute Care Transitions Program ensures seamless, compassionate care as patients move from hospital to home. Designed to support both patients and their families, the program connects individuals with community-based healthcare providers, social support services, primary care and acute care teams. Together, they create personalized plans that improve outcomes and ease the transition to home.

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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.

**RESPONSIBLITIES**:

- 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
- 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
- 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 programs 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 or 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 SE Health**

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.