Transitions Care Lead

SE Health; Canada; Hybrid; CAD 69,000 - 87,000; Full time

Job summary

SE Health is seeking a Transitions Care Lead in Canada to manage care flow between hospital partners and community care teams, ensuring smooth transitions from hospital discharge to home.

You will coordinate referrals, track outcomes, and participate in quality improvement initiatives within Acute Transition programs, collaborating with interdisciplinary teams to meet performance targets.

Qualifications

• 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.
• Demonstrates strong critical thinking, problem-solving and self-directed skills.
• Excellent interpersonal communication and presentation skills with diverse stakeholders.

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 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 and place an initial equipment and supplies order as required.
• Ensure all necessary referral documents 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.
• Communicate patient risk-related events and monitor program metrics.
• Facilitate risk management per policies and procedures.
• Communicate patient and family concerns back to partner hospital and share action plans.
• Participate in program evaluation and process improvement.
• On-call as required for program support.
• Other duties to ensure the program runs smoothly.

Skills

Case management

Interdisciplinary collaboration

Decision making

Communication

Time management

Driver's license

Education

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

Tools

Microsoft Office

Job description

Hybrid position

Why join our team?

• Competitive Total Rewards. So much more than a paycheque! 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. Our leadership team is available 24/7 to help you practice to full scope and deliver excellent care. With diverse roles and locations across Canada, you’ll have opportunities to explore new career paths or move into support and leadership positions.
• Innovative.At SE, we are always looking for new, innovative ways to improve. You’ll be encouraged and supported to identify and make improvements to the way we do our work. As a social enterprise, we support research into Senior’s Health and Aging.
• Purpose & Impact Join a national social enterprise where your voice matters. Every role helps advance health, spark innovation and strengthen communities across Canada.
• Manage your life. At SE, you’ll be supported with the time you need to meet the needs of your clients and meet your own needs, develop yourself and your career, and be part of a team.
• 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, and to understand the home and life environments that impact recovery in a way you can’t in most other settings. At SE, you meet your patients where they are, and together you take them to new heights!

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 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 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 or 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 s k ills in M ic r o s o f t Off i ce (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. We’re All In Together.

Accessibility

If you require accommodations due to illness or disability, please contact Talent Acquisition at [e-mail].

AI And Compensation Details

We use AI to take notes during our interview. All applications and interviews are reviewed by our Talent Acquisition team. This role is a (new addition or replacement position). The hiring pay range is $69 000.00 - $87 000.00 per annum based on experience.