Transitions Care Lead

Position Summary The Acute Care Transitions Program ensures seamless, compassionate care as patients move from hospital to home. Designed to support both patients and their families, the program connects individuals with community-based healthcare providers, social support services, primary care and acute care teams. Together, they create personalized plans that improve outcomes and ease the transition to home. Remote role 12-month contract – 12-hour shift with every other weekend. As the Transitions Care Lead you will provide exemplary leadership and care flow management between hospital partners and community care teams while ensuring excellence in the provision of client care and the achievement of corporate/program objectives. This position will manage relations and collaborate with hospitals to ensure a smooth transition to a client’s home environment, meet performance targets, and participate in quality improvement initiatives to optimize patient flow and management processes within the Acute Transition programs. Why join our team? Competitive compensation – total rewards include salary, group benefits, RRSP pension, on demand pay and exclusive perks/discounts available only to SE Health staff. Develop yourself with SE – education bursaries, Tuition Assistance Programs, continuing education, training and professional development to support lifelong learning. Grow your career – SE Health is a large national organization with diverse healthcare business lines. Opportunities exist to perform different patient‑facing nursing roles in various locations or transition to supporting or leadership positions that build on nursing skills. Manage your life – flexibility to balance personal and client needs, career development and teamwork. Paid mileage between clients. Subsidized RNAO & RPNAO memberships. Mobile device and three uniforms provided. Responsibilities Act as the primary point of contact for the hospital navigator/coordinator. Receive, monitor and update the client tracking/notification/flow tools. Receive, review and accept referrals for in‑home transition services. Coordinate/liaise with hospital navigator/coordinator and SE @home Team as required. Participate in hospital discharge care conferences for complex clients as required. Prepare an initial care plan (e.g., for 48‑72 hours post transition) and place an initial equipment and supplies order as needed. Ensure all necessary referral documents and initial care plan instructions are received by SE @Home Team. Attend program huddles with hospital as per contract requirements. Monitor and communicate significant deviations from the care plan to the hospital as required. Communicate to the hospital any risk‑related events. Monitor timely completion and reporting outcomes of patient/family care conferences to partner hospital (required in contract) and monitor program metrics such as client experience, time to first visit, service volumes, risk events. Facilitate risk management as per established policies and procedures. Communicate patient and family complaints or issues back to partner hospital and share associated action plans in partner meetings. Participate in program evaluation and process improvement. Be on‑call as required for program support. Other duties to ensure the program runs smoothly. Requirements Membership in good standing with the applicable regulatory body: College of Nurses of Ontario, College of Physiotherapists of Ontario, College of Occupational Therapists of Ontario, Ontario College of Social Workers and Social Service Workers. 3+ years of recent experience in community health or a related field. Knowledge of the health care delivery system, including hospital discharge planning and community care and support services. Excellent case‑management skills and experience coordinating care within interdisciplinary teams. Excellent assessment and decision‑making skills. Passion for excellent customer service and experience. Strong critical thinking, problem‑solving and self‑directed skills. Excellent interpersonal communication and presentation skills with diverse stakeholders (hospital partners, front‑line staff, management team). Effective time‑management skills, with the ability to work independently and cooperatively in a busy multidisciplinary environment in various settings (hospital, office, community). Advanced skills in Microsoft Office (Word, Excel, PPT, Visio) and comfort with learning new technologies such as remote patient monitoring, virtual care technologies, EHR systems and reporting systems. A valid driver’s license and reliable vehicle. About SE Health At SE, we love what we do. Every day we bring hope and happiness to clients, homes and communities across Canada. We treat each person with dignity and love, build empathy and do the right thing. As a not‑for‑profit social enterprise, we share knowledge, provide the best care and help each client realize their most meaningful goals for health and wellbeing. We are an inclusive workplace offering competitive pay, benefits, pension and work‑life balance. In the interest of the health and safety of our patients, clients, employees and the greater community, SE Health requires that all employees be fully vaccinated against COVID‑19 (both doses and at least 14 days since the last dose). SE Health is committed to the success of all its employees. If you need accommodations because of illness or disability, please contact the Talent Acquisition team at as soon as possible. #J-18808-Ljbffr