Transition Lead

**Position Summary**

Transitional Leadership: The Transitional Lead works in collaboration with the client, family, substitute decision maker and community care providers to facilitate a holistic approach to care for persons presenting as high risk for responsive behaviours on transition to a long-term care facility.

The Transitional Lead will conduct a full assessment of the LTC eligible client, test recommendations and care strategies prior to transition and consult with other current community care providers including attending physician in order to create a Transitional Care Plan for implementation prior to and on arrival to the long-term care facility.

Episodic Escalations: On request from a LTCH; facilitates/ leads/ participates in a consultative case review (huddle) on previously supported clients where high-risk responsive behaviors are occurring and are not responding to the LTCH interventions and / strategies as outlined in the Responsive Behaviour Protocol in an attempt to prevent the transition of the resident to emergency services of a behavioral assessment unit.

**Location**:Based in Niagara and float for all BSO region in Haldimand/Norfolk/Brant/Hamilton

**Duties and Responsibilities Overview**
- Demonstrated skill including superior assessment skills, including screening for depression, psychosis, suicide risk, cognitive status, ability in the use of appropriate assessment tools, and excellent skills in formulating comprehensive assessments in mental health, treatment and non-pharmacologic therapeutic interventions
- Develops and maintains an effective working relationship with each LTCH, CCAC and external stakeholders
- Conducts regular speaking engagements and education in-services in member homes in their assigned regional hub regarding their role in transitional support.
- Develops and Implements regular quality improvement activities, implementation and evaluation of such.
- Develops and maintains effective referral and follow up system in collaboration with existing community resources and oversight committee.
- Assesses and prioritizes referrals based on client needs, potential date of LTCH admission and care requirements to ensure relationship building can be well established in advance of the LTCH admission
- Ensures regular and consistent communication through committee involvement and regular reporting as assigned by Director of Program and Services.
- Implements program changes as directed by the HBHNLHIN and authorized by the Director of Program and Services.
- Supervises and maintains all required BSO program documentation as per established BSO pathways.
- Maintains relationships and ongoing training and awareness with mental health program and supports within the community.
- Attends BSO meetings routinely as assigned
- Other duties as assigned by the Manager of Community Programs and Services

**FORMAL EDUCATION**
- A University degree and current registration in a related regulated health care profession
- Regulated profession in the following discipline, Social Worker, Occupational Therapist, Physio Therapist, RN
- Minimum 5 years demonstrated expertise in working with older adults with mental health illness
- Extensive knowledge, skills and experience in the assessment/care planning for older adults and the use of clinical assessment tools as they relate to complex physical health problems including pain, chronic disease management, delirium, metabolic disorders, cognitive function and impairment including dementia as well as other neurological disorders (additional familiarity with ABI and developmental disabilities co-occurring with a dementia is preferable), mental health care problems including mood disorders, anxiety, psychotic disorders with a variety of underlying causes, longstanding mental health illness including personality disorders, schizophrenia.

**OTHER KNOWLEDGE, SKILL AND EXPERIENCE**
- PIECES, Montessori Methods for Dementia, GPA certificates/ training preferred
- Familiarity with Quality Improvement, program development, evaluation and research methodology would be an asset.
- A minimum of 5 years health care experience working with complex older adults
- Demonstrated well developed knowledge of psychiatric and geriatric disorders.
- An ability to draw upon his/her own knowledge and experiences to confidently respond to clinical questions/situations in-the-moment as they arise in community, LTC and/or conference setting
- Excellent coaching skills and the ability to facilitate the development of these skills in others
- Expertise in acting as a team member, leader, mentor, educator, preceptor and maintain partnership networks
- Superior communication skills (verbal, written and interpersonal) and ability to adjust language or terminology to meet the needs of the audience.
- Demonstrated ability to manage workload, determine priorities and meet deadlines and adapt to and the ability to work in unpredictable stressful situations.
- Demonstrated abil