Transitions Care Lead

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

Why join our team?

• Competitive Total Rewards: Enjoy comprehensive benefits, pension, on-demand pay, car loan support, supportive housing and exclusive staff perks.
• Growth That Meets Your Ambition: Build your skills with education bursaries, tuition support, ongoing training and mentorship.
• Innovative: You’ll be encouraged and supported to identify and make improvements to the way we do our work.
• Purpose & Impact: Join a national social enterprise where your voice matters.
• Support to be your best: At SE you are afforded the time you need to help patients, to build rapport, to accomplish patient care and recovery goals.

POSITION SUMMARY

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.

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 conference 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 required.
• Ensure all necessary referral documents (e.g. transition request form, medical orders, consult notes, allied health reports) 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).
• 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.
• On-call as required for programs support.
• Other duties to ensure program is running smoothly.

REQUIREMENTS

• Membership, in good standing, with College of Nurses of Ontario.
• 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 decision-making skills.
• Passion for excellent customer service and customer experience.
• Demonstrates strong critical thinking, problem-solving and self-directed skills.
• Excellent interpersonal communication, and presentation skills with a diverse group of stakeholders (hospital partners, front line staff, management team).
• Effective time management skills, with the ability to work independently and co-operatively 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 SE Health

SE Health is a not-for-profit social enterprise advancing health with heart. With 115+ years of impact, we bring hope, happiness and exceptional care to people and communities across Canada. We lead with empathy, dignity and purpose while building a future where everyone can realize their full health and well-being potential. We’re also an inclusive, supportive workplace offering competitive compensation, strong benefits and real opportunities to grow.

COVID-19: To protect the health of our clients, teams, and communities, all SE Health employees must be fully vaccinated (two doses, 14+ days since the final dose).

Accessibility: If you require accommodations due to illness or disability, please contact Talent Acquisition at careers@sehc.com.