Transition Navigator

Michael Garron Hospital; Toronto; On-site; CAD 65,000 - 85,000; Full time

Job summary

Michael Garron Hospital in Toronto, Ontario seeks a Transition Navigator to lead patient-centered discharge planning from hospital to the next level of care, working within an interprofessional team to optimize outcomes.

The role emphasizes coordinating resources, understanding community options, and ensuring health literacy through teach-back and follow-up calls after discharge, with attention to cultural, financial, social, and spiritual needs.

Qualifications

• Bachelor’s degree in a healthcare field.
• Registration in good standing with relevant professional college.
• 2-3 years hospital-based acute care experience preferred.
• 2+ years transition/discharge planning experience preferred.
• Strong knowledge of community resources and legislation affecting transitions.

Responsibilities

• Plan and lead patient-centered transitions from hospital to next level of care.
• Coordinate discharge planning with interprofessional teams and families.
• Identify and link patients to appropriate community resources and services.
• Educate patients and families with teach-back to ensure health literacy.

Skills

Transition planning

Interprofessional teamwork

Communication skills

Negotiation skills

Resource identification

Care coordination

Education

Bachelor's degree in a healthcare field

Registration in good standing with relevant professional college

Tools

Electronic documentation systems

Community resources databases

Job description

Overview

The Transition Navigator provides comprehensive, patient-centered transition planning for patients from hospital to the next destination of care. The Transition Navigator is a key member of the interprofessional team. With a focus on the provision of excellence throughout the transition process, the Transition Navigator builds collaborative relationships and strives to deliver an exceptional patient/family experience through the health care journey. The Transition Navigator begins the transition process on patient admission and develops a plan for a transition out of hospital that considers the needs of the patient from a: cultural; financial; social; and spiritual perspective. The Transition Navigator works toward a seamless and sustainable transition, while utilizing their knowledge and understanding of community resources, legislation as it relates to Alternative Level of Care (ALC), Substitute Decision Makers Act, Public Guardian and Trustee and the Public Hospitals Act to reduce patient length of stay and readmissions rates. The Transition Navigator provides education and uses teach-back methodology to ensure health literacy is embedded into the transition process, with follow-up discharge phone calls at regular intervals, to ensure a smooth discharge.

Education

• Bachelors degree in a healthcare field.
• Registration in good standing with relevant professional college.

Qualifications

• 2-3 years recent experience in hospital-based acute care, in a professional field required.
• 2 years recent experience in transition/discharge planning required.
• Working knowledge of community resources, LHIN Home and Community Care, long term care facilities, rehabilitation and palliative care facilities/programs required.
• Experience working with the geriatric population and medical/surgical patients required.
• Demonstrated knowledge and skills in transition/discharge planning, conflict resolution and creative problem solving required.
• Demonstrated working knowledge of legislation including the Substitute Decision Makers Act, Alternative Level of Care, Public Hospitals Act.
• Experience working with the Resource Matching and Referral system and electronic documentation systems.
• Demonstrated ability to prioritize multiple competing workload demands.
• Superior communication and negotiation skills.
• Demonstrated ability to provide resource identification, referral and linking.
• Demonstrated ability to work collaboratively as a member of an interprofessional team.
• Demonstrated ability to build relationships with internal and external partners.
• Demonstrated ability to prioritize and work effectively in a fast paced environment required.
• Demonstrated patient centered philosophy of care provision.
• Good work and attendance record required
• All employees of Michael Garron Hospital (MGH), a division of Toronto East Health Network (TEHN) [formerly Toronto East General Hospital (TEGH)] agree to work within the legislated practices of the Occupational Health and Safety Act of Ontario.
• All employees of MGH are responsible to contribute to a transparent culture of patient and staff safety by adhering to and abiding by patient and staff safety policies and procedures set by MGH.
• All employees are accountable for protecting the psychological health and safety of themselves and their co-workers through adherence to MGH's policies and practices.

EMPLOYMENT EQUITY & ACCESSIBILITY STATEMENT

Michael Garron Hospital (MGH) champions accessibility, diversity and equal opportunity through the creation of an inclusive and diverse work environment. At Michael Garron Hospital, we strive to be an equitable and inclusive employer. We encourage candidates from Black, First Nations, Métis and Inuit, racialized and LGBTQ2S+ communities, people of colour, women, people with disabilities and individuals who identify with the diverse communities that we serve, to join the MGH team.

Through our values of Compassion, Respect, Integrity, Inclusion and Courage, Michael Garron Hospital is committed to providing accessible employment practices that are in compliance with the Accessibility for Ontarians with Disabilities Act (AODA) and Ontario Human Rights Code (OHRC). Should you require an accommodation at any stage of the recruitment process, please let us know how we can work with you to meet your needs.

This job posting is a confirmed, active vacancy for which we are currently seeking a qualified candidate.

MGH is committed to leveraging new technologies and working efficiently. As a result, artificial intelligence systems may be used as part of our process to screen, assess, and or select applicants for this position.