HEART@Home Navigator

Humber River Health. Lighting New Ways In Healthcare.
Since opening our doors in 2015 as North America's first fully digital hospital and we remain unwavering in our belief that we can change the hospital where we work, the community where we live, and the world of healthcare beyond our borders. Serving a community of 850,000 residents in North West Toronto, Equity Inclusivity and active participation in the North West Toronto Ontario Health Team are key initiatives important to our Team. At Humber River Health, we use a custom combination of technology and clinical expertise to rebuild elements of care. We make technology work for staff and physicians; giving them more time to spend with patients, to eliminate inefficiencies, and to reduce the chance of errors. Humber River Health is formally affiliated with both the University of Toronto and Queen's University and committed to becoming a community academic hospital. Clinical Excellence, Optimizing Care through Technology and Community Connection frame our Research Strategy.

At Humber River Health, we're not hoping for a renaissance, we are making it happen. As part of our dynamic team, you can lead the way, as we continue our journey towards high reliability care

We have an exciting opportunity for e
Full-Time Navigator
to join our team within Integrated Health Systems & Partnerships at Humber River Health. This experienced individual will coordinate and facilitate seamless transitions in care for medically complex and/or frail elderly patients. Do you have the experience, skills and passion to showcase your strengths and values as the Navigator? If yes, we invite you to read the requirements below and then complete the online application process

Availability:
Days/Afternoons, Monday to Friday (subject to change); weekend work may be required

Employee Status
: Full Time

Union
: Non-Union

Site:
Wilson (subject to change)

Reporting Relationship
: This position reports directly to the Manager, Schulich Family Medicine Teaching Unit and Integrated Care Services and is an integral member of the Post Acute and Reactivation Care Centres Program portfolio.

Responsibilities
Under immediate direction and work guidance of manager/director, some of the responsibilities of the role will include:

• Collaborate with social workers and managers of the emergency department and various inpatients departments across three sites to identify patients requiring services
• Receive and coordinate referrals from inpatient teams and departments, review relevant information from Electronic Patient Record to determine assessment and care planning
• Attend Joint Discharge Rounds, Long-Term Care rounds and in-patient bullet rounds (as necessary)
• Lead community and hospital transitional care conferences at designated points in the care pathway and as required
• Establish a plan to co-ordinate seamless care transitions in collaboration with the Patient Flow Managers, social workers managers, and community partners
• Formulate and execute appropriate clinical priority setting based on current needs, activity, resources and safety
• Provide orientation on the program and teaching/training on the referral process to SW, nursing and Allied Health staff to support effective transitions
• Liaise with members of the inter-professional teams within both the hospital and community to ensure excellence in patient care through monitoring of standards of care and patient outcomes
• Coordinate care delivery and the development of individualized care plans with internal and external stakeholders, including liaising with outside agencies to facilitate seamless care for patients in the community
• Collaborate with the manager and other stakeholders to organize the human and material resources required to facilitate service in the right quality, quantity, skill set, place and time
• Participate in the implementation, monitoring, and evaluation of program and escalate barriers to discharge in timely fashion
• Participate in internal and external committees/working groups
• Participate in patient experience debriefs
• Advocate to identify gaps in services required for safe transitions to the community
• Develop and fosters links with external partners to facilitate continuity of patient care
• Monitor overall usage of allocated resources and implement strategies that are developed to support the current budget and optimize program resources to support safe and effective patient care in the community

Qualifications

• Successful completion of Nursing, MSW or related discipline
• Licensed healthcare professional with current registration and membership in good standing with respective health professional regulatory body in Ontario
• RNAO, or equivalent; other professional affiliations as appropriate
• 3 years of experience in Care coordination, navigation or advocacy and discharge planning in a healthcare setting
• Project work experience within a health care environment, preferred
• Demonstrates knowledge in clinical practice in the area of medical complexity and frail seniors
• Demonstrates a strong patient and customer focused philosophy in all interactions
• Possesses the ability to implement strategies that effectively facilitate change
• Demonstrates clinical decision-making and organizational skills
• Demonstrates the ability to support the clinical team in a professional manner
• Demonstrates proficiency in using MS office (Outlook, Word, Excel, PowerPoint etc.)
• Knowledge of community and government resources and relevant legislation
• Skilled in quality improvement processes and data analysis
• Excellent assessment, negotiation and problem-solving skills
• Excellent interpersonal, communication, organization and time management skills
• Excellent team player who is capable of working both independently and interdependently
• Ability to build and maintain relationships with hospital staff and community partners and manage conflicting priorities
• Must be able to practice in a culturally sensitive manner
• Ability to work in a fast-paced, physically demanding hospital environment
• Demonstrated excellence in communication, both written and verbal
• Excellent attendance and discipling free record required
• Valid driver's license and access to a vehicle for travel between the three sites

Why Choose Humber River Health
At Humber River Health, our staff, physicians, and volunteers are lighting new ways in healthcare. We are proud to be recognized as a part of Greater Toronto's Top Employers by Mediacorp Canada Inc. We support employees by providing evidence-based leadership and cultivating a culture that consistently wows with our unwavering commitment to Staff, Physician and Volunteer engagement. We are a member of the Toronto Academic Health Science Network (TAHSN) and are deeply involved in research and academic collaboration. We are dedicated to high-quality patient care and demonstrate our values of compassion, professionalism, and respect.

Attracting and retaining a workforce that represents the diverse communities surrounding Humber River Health, is a priority. We encourage applicants from all equity-deserving groups, including but not limited to, individuals who identity as Indigenous, racialized, seniors, persons living with disabilities, women, and those who identify as 2SLGBTQ.

Applicants will not be discriminated against on the basis of race, creed, sex, sexual orientation, gender identity or expression, age, religion, disability, medical condition, or any protected category prohibited by the Ontario Human Rights Code and Accessibility for Ontarians with Disabilities Act.

Accommodations are available throughout the recruitment process as well as during employment at Humber River Health. Please direct any accommodation requests to our recruitment team.