Care & Transitions Facilitator - Hlv Program

The Care & Transitions Facilitator is a practitioner in the Heart Lung and Vascular program that is results oriented committed to enhance the quality of patient care within the Schroeder Brain & Heart Institute - a complex health, social and fiscal environment. As a clinical expert, you will be instrumental in coordinating the use of clinical resources for patients being considered for cardiac - cath lab heart procedures. Working collaboratively with interdisciplinary teams, you will be responsible for facilitating the patient journey within the aortic program and responsible for facilitating the patient journey from referral to post-operative long term follow up. This will involve acting as an advocate and liaison for patients through assessment and diagnostics, care planning and transitions and education for patients with aortic diseases requiring complex care coordination and proactive medical management. A key component of the role is utilization management related to daily patient access and flow.

Other duties include:

- Patient assessment and triage inclusive of being a resource for patients to call with questions through their care journey
- Educating (and the development/implementation of education material) patients/families, students, Residents and new or allied staff;
- Participation in research related initiatives as required by the clinic team;
- Coordinating multiple referrals through testing and care pathways;
- Networking and building community and internal partnerships; and
- Identifying and leading unit based quality initiatives.

**RESPONSIBILITIES**
- Care Facilitation:_
- Working with Heart Teams, you will:_
- Assess the needs of patients and families working to advance all patient journeys in order to reduce delays in service/disposition for Aortic heart patients from referral to procedure and beyond.
- Lead/attend weekly clinic(s) including meeting with all new aortic surgical patients. Providing information on type of procedure, surgical work up, testing, surgical pathway, post-surgical follow up. Provide contact information and act as one point of contact for surgical patients.
- Ensure development, implementation and evaluation of intra-disciplinary care plans for patients with clear treatment goals including schedules/routines
- Coordinate clinical resource use for exceptional and complex patients
- Communicate effectively with medical/interdisciplinary/unit teams and patients/families adjudicating daily plans of care to enrich patient progress
- Coordinate care delivery with internal and external stakeholders liaising with outside agencies to facilitate the initiation of timely and appropriate medical, functional testing and services
- Advocate for patient services needed for a safe and effective care from referral to procedure and beyond.
- Negotiate care pathways for patients to deescalate concerns providing guidance and education where applicable to assist with difficult decision-making
- Identify patient care/safety issues working to resolve issues and communicate concerns to the MRP or unit Clinical Leader Manager (CLM)
- Circulate daily through clinic, communicating and collaborating about patient care needs/goals with support service teams to ensure optimized clinical process efficiencies and patient transitions
- Utilize expert knowledge and leverage external resources to reduce system barriers and facilitate safe and timely care and testing, discharges as required
- Maintain collaborative relationships with clinic clerical support
- Collaborate with medical leadership and CLM and optimize resources to achieve ministry targets
- Participate in cross-training as deemed necessary by program leadership and provide coverage to other clinical areas within the Heart, Lung, and Vascular program
- Under the direction of the CLM, act as a resource for patient care issues and problem solve in collaboration with cross program and community teams to ensure effective and efficient patient testing, care, access, flow, and transitions in care
- Education:_
- Provide direct patient education about their open heart surgery procedures.
- Educate patients and families with regards to the patient journey of care inclusive of coordination of testing, care, and transitions.
- Facilitate communication of changes in practice, protocols, education and other relevant material to Hospital staff/physicians
- Under the direction of the CLM act as clinical resource for the interdisciplinary team and front line staff
- Encourage the interdisciplinary team’s active involvement in patient care plan and discharge activities
- Collaborate with CLM to engage staff and physicians to reach consensus related to care by providing direct or indirect assistance, guidance or supervision along the continuum of care
- Quality Improvement/Research:_
- Update knowledge by participating in educational opportunities, reading professional publications, maintaining personal networks, participating in professional orga