Transition Navigator

Michael Garron Hospital; Toronto; On-site; CAD 70,000 - 85,000; Full time

Job summary

A leading hospital in Toronto seeks a Transition Navigator to enhance patient care during transitions from hospital to other care settings. The role emphasizes collaborative relationships and comprehensive planning to ensure smooth discharges, focusing on patient needs and community resources. Ideal candidates will have a healthcare degree and relevant experience in discharge planning, with strong communication and problem-solving skills.

Qualifications

• 2-3 years recent experience in hospital-based acute care.
• 2 years recent experience in transition/discharge planning.

Responsibilities

• Provide patient-centered transition planning from hospital to next care destination.
• Develop discharge plans considering cultural, financial, social, and spiritual needs.

Skills

Communication

Problem Solving

Negotiation

Conflict Resolution

Education

Bachelor's degree in a healthcare field

Tools

Resource Matching and Referral systems

Electronic documentation

Job description

Overview

The Transition Navigator provides comprehensive, patient-centered transition planning for patients moving from hospital to the next destination of care. As a key member of the interprofessional team, the Transition Navigator focuses on delivering excellence throughout the transition process, building collaborative relationships, and ensuring an exceptional patient and family experience. The role begins at patient admission, developing a plan for discharge that considers the patient's cultural, financial, social, and spiritual needs. The Navigator aims for seamless, sustainable transitions by leveraging knowledge of community resources, relevant legislation (such as ALC, Substitute Decision Makers Act, Public Guardian and Trustee, and Public Hospitals Act), to reduce patient length of stay and readmission rates. Education efforts include patient teaching using teach-back methods and follow-up calls to ensure smooth discharges.

Education

- Bachelor's degree in a healthcare field.
- Registration in good standing with the relevant professional college.

Qualifications

- 2-3 years recent experience in hospital-based acute care.
- 2 years recent experience in transition/discharge planning.
- Knowledge of community resources, LHIN Home and Community Care, long-term care, rehabilitation, and palliative care facilities/programs.
- Experience working with geriatric and medical/surgical patients.
- Skills in transition/discharge planning, conflict resolution, and creative problem solving.
- Knowledge of legislation including the Substitute Decision Makers Act, ALC, and the Public Hospitals Act.
- Experience with Resource Matching and Referral systems and electronic documentation.
- Ability to prioritize multiple demands.
- Strong communication and negotiation skills.
- Ability to identify resources, make referrals, and link patients to services.
- Ability to work collaboratively in an interprofessional team.
- Ability to build relationships with internal and external partners.
- Capacity to work effectively in a fast-paced environment.
- Patient-centered care philosophy.
- Good work and attendance record.
- Commitment to safety, adhering to Occupational Health and Safety Act and hospital safety policies.
- Responsibility to promote psychological health and safety among staff and colleagues.