Transitions Care Lead - York, Canada - SE Health

SE Health

Verified Company

York, Canada

1 week ago

Posted by:

Sophia Lee

beBee Recruiter

Description

About the Role

An exciting leadership role within hospital transitional programs working with closely with hospitals to transition and reintegrate clients back into the community.

As a member of the Acute Transitions leadership team, you are passionate about informing and shaping the transition from hospital to home and being at the forefront of healthcare innovation in Canada.

Hybrid role (virtual /in-person) covering Newmarket and surrounding areas.

Hours are primarily during business hours Monday-Friday and can also be irregular and include on-call to support operational requirements.

As the Transitions Care Lead You will provide exemplary leadership and care flow management between the hospital partners and community care teams while ensuring excellence in the provision of client care and the achievement of corporate/program objectives.

This exciting position will manage relations and collaborate with hospitals to ensure a smooth and seamless transition to a client's home environment.

Additionally this position will help to ensure performance targets are met and be involved in quality improvement initiatives as it relates to optimizing patient flow and management processes within the Acute Transition programs.

Main 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 inhome transition services
Participate in hospital discharge care conference for complex clients as required
Prepare an initial care plan (e.g. for 4872 hours post transition) and place an initial equipment and supplies order as required
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 riskrelated events
Monitor timely completion and reporting outcomes of patient/family care conferences to partner hospital(required in contract)Monitor Program Metrics (e.g. client experience, time to first visit, service volumes, risk events, etc.)
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
Oncall as required for programs support
Other duties to ensure program is running 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, community care and support services
Excellent skills in case management and coordinating care within interdisciplinary teams
Excellent assessment and decisionmaking skills
Passion for excellent customer service and customer experience
Demonstrates strong critical thinking, problemsolving and selfdirected skills.
Excellent interpersonal communication, and presentation skills with a diverse group or 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 (e.g. at the hospital, in the office, in the community).
Advanced skills in Microsoft Office (Word, Excel, PPT, Visio) and comfort with learning/working with new and emerging technologies (e.g. remote patient monitoring/virtual care technologies, EHR systems, reporting systems)
A valid driver's license and access to a reliable vehicle.

About Us:

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, like our own family; we build empathy; and we do the right thing.

We are always inspired to make a difference.

As a not-for-profit social enterprise, we share knowledge, provide the best care, and help each client to realize their most meaningful goals for health and wellbeing.

We are an inclusive workplace offering competitive pay, benefits, pension, and work life balance. We're a great place to work, and we hope you'll join our team.

In the interest of the health and safety of our patients/clients, employees, and greater good of public health, SE Health requires those that wish to work for this organization to be fully vaccinated against COVID-19.

Fully vaccinated means a person has received both doses of the COVID-19 vaccine and it has been 14 days since the last dose.