Transitional Care Lead

**About SPRINT Senior Care**:
We began caring for seniors and enabling seniors to care for themselves in 1983. We continue to do so today as an accredited, not-for-profit community support service agency in Toronto by offering a wide range of practical and low-cost services to seniors and their caregivers. Our services help seniors stay safe, connected, and live as independently as possible. They also prevent premature or inappropriate institutionalization. We supply services regardless of ability, race, colour, ethnic origin, marital status, sexual orientation, religion, gender identity and gender expression, and are committed to 2SLGBTQ+ inclusiveness.

**Program Description**:
Sunnybrookto-Home is a collaborative partnership with Sunnybrook Hospital, SE Health and VHA Home Healthcare. The client-centred initiative enables timely and seamless transitions home from hospital, and provides integrated, comprehensive care in the home or community. The initiative aims to reduce emergency visits to hospitals and hospital length of stay; enhance the care experience of clients, family, and caregivers; and develop a new model of healthcare to support clients in receiving the right care in their own homes.

The Transitional Care Lead will act as the main linkage between the client(s) and the hospital and home care teams. A key component of the position will be to coordinate both home care services through a Service Provider Organization partner and build a support network of community resources used to link clients and increase their independence, dignity and self-respect in a secure community environment.

**What you will do**:

- Provide leadership, client, family and caregiver centred navigation, case management, and coordination of hospital, home care and community care services.
- Work with hospital social workers, discharge planners and other transitional care leads to identify appropriate/eligible clients for Sunnybrook-to-Home services.
- Act as liaison and coordinator between clients, the hospital team, and home and community care providers, to ensure all components of a patient’s health and social care are provided post discharge.
- Work collaboratively with the clinical team, family and caregivers, and home and community care to ensure ongoing patient assessment and adapting care plans to meet patient changing needs.
- Develop realistic and innovative transitional plans in collaboration with clients, families, caregivers, and home care teams for reintegration back to the community.
- Refer and connect patients to community support services in collaboration with clients, families, caregivers and home care teams.
- Provide leadership, coaching and ongoing clinical information - to care team members, including other transitional care leads and home and community partners regarding Sunnybrook-to-Home and its clients.
- Monitor and collaborate with Sunnybrook-to-Home team to ensure that the patient and system level objectives of Sunnybrook-to-Home are met.
- Collaborate with Sunnybrook-to-Home Project Manager to support ongoing development, innovation and advancement with regular collection of Sunnybrook-to-Home data, metrics and client care statistical tracking.
- Provide back up and coverage for the Manager of Social Work and other Transitional Care Leads.
- Supervise assigned staff and support the Manager, Social Work in managing the Transitional Care department.
- Oversee the planning, coordination and facilitation of caregiver support through the provision of self-help, therapeutic, problem-solving, and educational group programs.
- Participate in and provide leadership to current SPRINT Senior Care partnerships, such as with Sunnybrook Health Sciences Centre, and establish new partnerships to support community-organizing activities.
- Develop and maintain excellent collaborative relationships with referral sources and resources.
- Participate in the development, implementation and evaluation of quality and risk management activities of the department and agency.
- Ensure that the agency’s programs and services are delivered within the agency’s mandate, mission, vision and values, objectives, and policies and procedures, within relevant legislative requirements.
- Off hours may be occasional required based on client needs. Ability to work flexible hours as required.

**What you will need**:

- BSW or greater, or other related professional designation.
- Minimum of two years of experience working in gerontology and/or community setting.
- Strong supervisory skills.
- Excellent communication and interpersonal skills, with the ability to establish good rapport with staff, clients, families, and referral sources in a multi-cultural setting.
- Excellent understanding of the aging process, dementia and the specific needs of the elderly, disabled and caregivers.
- Experience working with individual caregivers.
- Sensitive to the cultural needs of clients from various ethnic groups.
- Committed to SPRINT Senior C