Transitions Care Lead

**Make an Impact on People’s Lives; Join SE Health as a **Transitions Care Lead****

This is an exciting SE Health role providing clinical and operational leadership to hospital to home transitions programs and coaching self-directed interdisciplinary teams who will be providing holistic care to clients in the community.

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.

**The position is 14 months contract role**

**Why join our team?**
- **Competitive Compensation**. Our Total Rewards package includes a competitive salary, group benefits, RRSP pension, and exclusive perks/discounts available only to SE Health staff.
- **Develop yourself with SE.** We have education bursaries, Tuition Assistance Programs, continuing education, training, and professional development to support your life-long learning. You’ll benefit from our orientation and mentorship programs. Our clinical practice and nursing teams will support you with comprehensive care plans and modern models of care that will mean you’ll always be supported to provide the best possible care to your clients.
- **Grow your career.** SE health is a large national organization with diverse healthcare business lines. You’ll have an opportunity - and will be supported - to do different types of roles in different locations if that is what you’re interested in. Or you can pivot to supporting or leadership positions where you can use your skills to contribute and make an impact in different ways.

**Key Responsibilities**
- 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 transition program services
- Coordinate/Liaise with hospital navigator/coordinator and SE Transitions Team as required.
- Participate in hospital discharge care conferences 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
- Ensure all necessary referral documents (e.g. transition request form, medical orders, consult notes, allied health reports) and initial care plan instructions are received by SE Transitions Team
- 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 program support
- Other duties to ensure the program is running smoothly
- Role is on-site at the hospital

**Qualifications**
- 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 of 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,