Scope/ltc+ Navigator

Position Profile:
**Humber River Health. Lighting New Ways In Healthcare.**

Since opening our doors in 2015 as North America’s first fully digital hospital, we remain unwavering in our belief that we can change the hospital where we work, the community where we live, and the world of healthcare beyond our borders. Serving a community of 850,000 residents in North West Toronto, Equity Inclusivity and active participation in the North West Toronto Ontario Health Team are key initiatives important to our Team. At Humber River Health, we use a custom combination of technology and clinical expertise to rebuild elements of care. We make technology work for staff and physicians; giving them more time to spend with patients, to eliminate inefficiencies, and to reduce the chance of errors. Humber River Health is formally affiliated with both the University of Toronto and Queen’s University and committed to becoming a community academic hospital. Clinical Excellence, Optimizing Care through Technology and Community Connection frame our Research Strategy.

At Humber River Health, we’re not hoping for a renaissance, we are making it happen. As part of our dynamic team, you can lead the way, as we continue our journey towards high reliability care

We have an exciting opportunity for a Temporary Full-Time SCOPE/LTC+ Navigator to join our team within Integrated Health Systems & Partnerships at Humber River Health. 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. SCOPE aims 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.

grams.

**Employment Status**: Temporary Full Time
**Duration**:up to January 3, 2027

**Location**: Humber River Health, Wilson Site
**Labour Group**:Non Union**
**Reporting Relationship**:Manager, Integrated Transitions in Care

**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