Company Description

One of Canada's Best Diversity Employers and Greater Toronto's Top Employers for many consecutive years, William Osler Health System (Osler) provides a safe and supportive health care network to grow your career. Osler is nationally recognized for its commitment to patient safety and is Accredited with Exemplary Standing, the highest rating a Canadian hospital can receive. As a major Ontario hospital system, and home to some of the biggest specialty and emergency departments in the country, Osler serves the 1.3 million residents of Brampton, Etobicoke and surrounding communities. We are proud to offer you incredible exposure to best-in-class health care delivery and challenging hands-on opportunities to stay at the top of your game.

A hospital system built for and by the community, we continue to expand our services to meet the needs of a growing population, creating opportunities for increased hands-on skills development, cross-department training and promotional opportunities. Guided by our accomplished senior leadership team, together we are driving our vision of patient-inspired health care without boundaries.

At Osler, we invest in careers that go beyond where health care professionals like you can achieve their goals and find deep personal and professional fulfillment. Join our team today!

Job Description

The Transitional Care Coordinator practices in accordance with standards of professional practice and the Osler corporate mission, vision and values that support a model of inter-professional collaboration as a vehicle to facilitate practice culture and support a patient-focused model of care. The Transitional Care Coordinator supports the delivery of a superior care experience to all patients and their families by practicing as an equal member of a core team of skilled professionals working to full scope of practice to ensure that each patient has a comprehensive patient assessment, care plan and timely and effective discharge plan.

Accountabilities:

In collaboration with the inter-professional team, the Transitional Care Coordinator coordinates decision-making for patient transfer and discharge beginning at the point of admission and throughout the hospitalization:

Screens all admissions for early identification of high-risk discharges (within 24 hours of admission) and documents accordinglyConducts a risk assessment using standardized tools and communicates results of the risk assessment to the inter-professional teamMeets with the patient and family to determine pre-admission physical and mental functioning as it relates to activities of daily livingIdentifies pertinent demographic and health related information, care giver support, community resources, and any previous discharge planning assessments that may impact on the discharge planWithin 24 hours of a diagnosis being communicated, collaborates with the patient, family and inter-professional team to develop and implement an effective discharge plan that identifies barriers and solutionsInitiates, arranges and facilitates case conferences for management of patient care issues such as determining families understanding of discharge clinical care needs, identifying concerns regarding services and co-ordination and identifying short and long-term goals in planning dischargeEnsures early collaboration with the Home and Community Care Support Services case managers on all patients likely to require post discharge supportWorks in collaboration with the Home and Community Care Support Services case manager and external agencies to develop and implement the individualized plan of care to facilitate discharge and provide guidance to patients and their families pertaining to relevant community agencies to support their needsCollaborates daily (more frequently as required) with the inter-professional team, including the most responsible physician, to uphold and revise as necessary a timely discharge planDocuments and communicates discharge plans to the patient, family and the inter-professional teamDocuments assessments and other relevant information in Meditech and at bullet roundsFollows the patient's discharge progress through to discharge destinationAttends bullet rounds and initiates and/or participates in identifying the expected date of discharge and mobilizing the team to work towards a common goalMaintains accurate records and statistical information and identifies ALC and actual length of stay information against expected length of stayMonitors for extended length of stay beyond the estimated date of discharge and facilitates discussion at bullet rounds to minimize or remove risks and barriers to timely dischargeCollaborates with other discharge coordinators in developing strategies for extended length of stay at difficult to discharge rounds and communicates strategies to patient care managersAttends daily bed management meeting and provides updates related to the patient discharge status, transitional requirements and repatriation issuesProvides education, communication and assistance to the patient and family as well as the inter-professional teamProvides leadership to inter-professional team to assist patients through the health care continuumIdentifies appropriate spokesperson for the patient if the patient is incapable of making decisions and collaborates with social worker in confirming substitute decision-maker and power of attorney

QualificationsBachelor's Degree in a health related disciplinePost diploma education/experience in gerontologyMinimum three to five years recent acute care hospital and community experienceOne year experience in case management, utilization review or equivalentRegulated health care professionalMember in good standing of a professional collegeMinimum one to two years in a leadership position

Additional Information

Hours: Currently Days/Evenings, 8 hours, including weekends and statutory holidays (subject to change in accordance with operational requirements)

Salary:
 Minimum:     $43.97 per hour
 Maximum:    $56.77 per hour

Internal application deadline: February 27, 2025

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Osler values inclusivity and diversity in the workplace. We welcome and encourage applicants from diverse backgrounds. We are committed to providing accessible employment practices that are in compliance with the Accessibility for Ontarians with Disabilities Act. If you require an accommodation at any stage of the recruitment process, please notify Human Resources at [email protected].

While we thank all applicants, only those selected for an interview will be contacted. Any information obtained during the course of recruitment will be used for employment recruitment purposes only, and not for any other purpose.