Care & Transitions Facilitator - Gen. Surg/gastro - Toronto, Canada - St Michael's hospital

St Michael's hospital

Verified Company

Toronto, Canada

1 week ago

Posted by:

Sophia Lee

beBee Recruiter

Description

The Care & Transitions Facilitator is a practitioner in the Specialized Complex Care (SCC) program that is results oriented and committed to enhance the quality of patient care within a complex health, social and fiscal environment.

In this role, you will be supporting 16CN (GI/General Surgery/Plastics) and 8PGT (Hematology/Oncology) Inpatient Units. 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 Surgical/GI/Plastics/Oncology
Demonstrated a