Transitions Care Lead

SE Health; Belleville; On-site; CAD 70,000 - 90,000; Full time

Job summary

Join a leading healthcare organization as a Transitions Care Lead, focusing on improving client transitions from hospital to home. This full-time, on-site role involves collaboration with hospitals and community care teams to ensure excellent client care and operational efficiency.

Benefits

Competitive Pay

Benefits

Pension

Work-Life Balance

Accommodations for Illness or Disability

Qualifications

• At least 3 years of recent experience in community health or related fields.
• Membership in good standing with applicable regulatory bodies.

Responsibilities

• Act as the primary contact for hospital navigators/coordinators.
• Monitor and update client tracking and flow tools.
• Coordinate with hospital navigators and the SE @home team.

Skills

Leadership

Case Management

Interdisciplinary Care Coordination

Communication

Problem-Solving

Time Management

Tools

Microsoft Office

Job description

Join to apply for the Transitions Care Lead role at SE Health.

About The Role

An exciting leadership position within hospital transitional programs, working closely with hospitals to facilitate client transition and reintegration into the community.

As a member of the Acute Transitions leadership team, you will be passionate about improving the transition from hospital to home and leading healthcare innovation in Canada. You will provide leadership and manage care flow between hospital partners and community care teams, ensuring excellent client care and meeting corporate objectives. Your role will involve collaborating with hospitals for seamless transitions, meeting performance targets, and participating in quality improvement initiatives related to patient flow and management processes within the Acute Transition programs.

Full-time role - on-site at Hospital Location

Main Responsibilities

1. Act as the primary contact for hospital navigators/coordinators.
2. Monitor and update client tracking and flow tools.
3. Review and accept referrals for in-home transition services.
4. Coordinate with hospital navigators and the SE @home team.
5. Participate in hospital discharge care conferences for complex clients.
6. Prepare initial care plans and order equipment and supplies as needed.
7. Ensure all referral documents and care instructions are received by the SE @Home Team.
8. Attend program huddles with hospitals as per contract.
9. Monitor deviations from care plans and communicate with hospitals.
10. Report significant events and risk-related issues.
11. Track and report program metrics.
12. Manage risks according to policies.
13. Address patient and family complaints and share action plans.
14. Participate in program evaluation and improvements.
15. Provide on-call support as required.
16. Perform other duties to ensure smooth program operation.

Requirements

• Membership, in good standing, with applicable regulatory bodies (e.g., College of Nurses of Ontario, College of Physiotherapists of Ontario, etc.).
• At least 3 years of recent experience in community health or related fields.
• Knowledge of healthcare delivery, hospital discharge planning, and community care services.
• Strong skills in case management and interdisciplinary care coordination.
• Excellent assessment, decision-making, and interpersonal skills.
• Customer service-oriented mindset.
• Critical thinking and problem-solving skills.
• Effective communication skills with diverse stakeholders.
• Good time management and ability to work independently and collaboratively.
• Proficiency in Microsoft Office and comfort with new technologies.
• Valid driver’s license and access to a reliable vehicle.

About Us

SE Health is dedicated to bringing hope and happiness to clients across Canada, emphasizing dignity, empathy, and doing the right thing. We are an inclusive, not-for-profit social enterprise offering competitive pay, benefits, pension, and work-life balance. We prioritize health and safety, requiring full COVID-19 vaccination for employment. We support employee success and provide accommodations for illness or disability.