Care & Transitions Facilitator (General Internal

The Care & Transitions Facilitator is a practitioner in the General Internal Medicine program that is results oriented and committed to enhance the quality of patient care within a complex health, social and fiscal environment. As a clinical expert, you will be instrumental in coordinating the use of clinical resources for inpatient cases. Working collaboratively with interdisciplinary teams, you will be responsible for facilitating the patient journey from admission to discharge through assessment, care planning, transitions and evaluation of care for the patient population. A key component of the role is utilization management related to daily patient access and flow.

Other duties include:

- Educating patients/families, students, Residents and new staff;
- Coordinating multiple referrals;
- Networking and building community and internal partnerships;
- Identifying and leading unit based quality initiatives.

**RESPONSIBILITIES**:

- Care Facilitation:_
- Assess the needs of patients and families working to advance all patient journeys in order to reduce delays in service/disposition
- 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 and rehab services
- Advocate for patient services needed for a safe and effective discharge/transition
- Negotiate with reluctant or challenging patients for limited services or space
- Identify patient care/safety issues working to resolve issues and communicate concerns to the unit Clinical Leader Manager (CLM)
- Circulate daily through unit, 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 discharges as required
- 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 access, flow, and transitions in care
- Education:_
- 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 bedside nurses’ active involvement in patient care plan and discharge activities
- Collaborate with CLM to engage staff to reach consensus related to care by providing direct or indirect assistance, guidance or supervision along the continuum of care
- Provide orientation related to patient flow on the unit/organization e.g. BED, ELOS, ALC
- Quality Improvement/Research:_
- Update knowledge by participating in educational opportunities, reading professional publications, maintaining personal networks, participating in professional organization
- Support the CLM and team in the implementation of unit/program based quality improvement initiatives
- Facilitate a multidisciplinary approach to quality and cost-effective complex patient care in the acute setting
- Offer strategic counsel to program leaders and unit staff to assist in prioritizing care issues related to patient flow, utilization and staffing as well as system issues/barriers through analysis of core metrics such as, but not limited to: ALOS, BELOS, Ambulatory volumes
- Monitor patient flow to analyze throughput and hospital wide demand and capacity status
- Identify/analyze care practices & system processes that contribute to/impede outcomes and make recommendations related to evaluation and redesigning processes
- Administrative:_
- Participate/lead daily interdisciplinary rounds
- Develop care management tools (assist in development of care maps/patient protocols for high volume procedures/diagnosis)
- Engage After-hours Clinical Managers and / or CLM in any situations that may need support beyond day shift
- Participate in internal and external committees/working groups
- Performs cross functional and other duties as assigned and/or requested

**QUALIFICATIONS**:

- Regulated Health Professional with a Bachelor of Science Degree in Nursing/Health Discipline required
- Registration in good standing with a regulatory college is required
- Master's degree would be considered an asset
- Current and advanced clinical assessment skills related to the needs of the program are required in the area of Internal Medicine, Addictions, Marginalized Populations, Frail Elderly and Stroke
- Minimum 5 years’ expe