Position:  Care Navigator

Job ID:  2024-39193

Status:  Permanent Full-Time (2)

Role Level:  Allied Health (AH10.6) - $44.67 to $57.90 per hour

Dept/Program:  THP@home, Primary & Integrated Care

Site(s):  Mississauga Hospital & Credit Valley Hospital 

Hours of Work/Shifts:  8 & 12 Hour Shifts - Days

Posted:  October 11, 2024

Internal Deadline:  October 18, 2024

Trillium Health Partners (THP) is one of the largest community-based acute care facilities in Canada. Comprised of the Credit Valley Hospital, the Mississauga Hospital and the Queensway Health Centre, Trillium Health Partners serves the growing and diverse populations of Mississauga, West Toronto and surrounding communities and is a teaching hospital affiliated with the University of Toronto.

Our Mission:     A New Kind of Health Care for a Healthier Community

Our Values:       Compassion, Excellence, Courage

Our Goals:        Quality, Access, Sustainability

Our Enablers:    People, Education, Innovation, Research

THP@home is an innovative program at Trillium Health Partners which integrates ED and hospital care with services and supports at home, through direct partnership between THP, homecare providers, community care and primary care. THP@home enables a safe and supported discharge from ED or inpatient units and allows the patient to return home with wrap-around supports – avoiding an admission from ED or shortening a stay in hospital. The target population is older adult patients with complex health and/or social needs.

This program is based on best practices for integrated and transitional care from around the world, and has been launched to help reduce hospital overcapacity – the most pertinent issue in healthcare at this time. THP@home will ensure delivery of the right care, at the right time, in the right place.

Position Description:

We have an exciting opportunity for a Full-Time Care Navigator, THP@home to join our team within Primary and Integrated Care program as we design, build and expand our integrated care programs as strategies to improve hospital capacity, relationships with primary care providers, transition to community providers and outcomes for patients through innovative partnerships and novel solutions.

Working collaboratively with an inter-professional team, both internal and external to THP and which include family members and support networks, the Care Navigator will identify and facilitate access this program for rapid access to care that enables admission to hospital and/or reduction in hospital length of stay.

Reporting to the Manager, Primary and Integrated Care, the Care Navigator will assess patients in ED or inpatient units, arrange for expedited transportation and supports at home, collaborate with community and primary care providers, phone patients at home for follow-up, and assist with health care navigation and accessing community resources. The Care Navigator will act as a liaison between patients and other care providers. This program leverages technology to support patient care and seamless transitions from hospital to community and ongoing community management.

In addition to operational responsibilities, this role will have leadership accountabilities in the development of THP@home, fostering strong relationships with service providers, staff, physicians, and leaders, and reporting on / monitoring metrics and key performance indicators.

Responsibilities:

• Play a leadership role in the implementation, monitoring and evaluation of THP@home program
• Enhance work-flow and communication between hospital, primary care, home care and community care by identifying barriers to access, and work towards creating pathways to promote and optimize care for the patient
• Advocate for, and contribute to, the establishment of organizational structures and resources to support the growth of the THP@home
• Identify gaps in the program needed to meet its purpose and targets, and system level changes required to meet changing needs of the patient population
• Develop and foster links with external partners to facilitate continuity of patient care; including community outreach
• Work with ED and inpatient unit staff, including Physicians, Discharge Planners and Geriatric Nurses, to identify patients arriving to the ED or in inpatient units who may be eligible for THP@home
• Attend Case Conference calls with homecare and community support providers to arrange for expedited transportation and supports at home, with the intention to discharge patients quickly and effectively – avoiding an admission from ED, or shortening a stay in hospital
• Collaborate with primary care providers to ensure the patient has necessary medical oversight and a complete care plan while supported at home
• Call patients after they have returned home for follow-up and prevention of further ED visits. Use expert decision-making and evidence informed tools to provide triage and symptom management advice over the telephone
• Ensure seamless navigation of services and supports required by the patient; triage and forward referrals to appropriate community services. Provide information and assist patients and families to overcome barriers
• Communicate and collaborate with patients, families, members of the health care team, and community resources to facilitate decision making regarding appropriate services. Act as a patient advocate
• Collect data for reporting, monitoring and evaluation

Qualifications:

• Degree in a Regulated Health Profession discipline
• Current membership in good standing with a regulatory health professional body in Ontario
• Three (3) years of recent related experience in ED, acute care, discharge planning, and/or community health care setting

Competencies:

• Comprehensive knowledge of community resources and health care delivery systems in acute and community settings
• Demonstrated ability to respond to patients with flexibility and adaptability
• Experience in performing case management functions is required
• Demonstrated expertise and competence in symptom management for areas of patient need, such as chronic disease management, complex family systems and the frail elderly
• Evidence of program design and resources development skills, including knowledge of evaluation methodologies
• Comfortable working in an evolving program, with changing responsibilities over time
• Demonstrated ability to develop collaborative practices internally and in the community
• Excellent interpersonal, communication, organizational and decision making skills required
• Consistently demonstrated strong leadership skills, including problem solving, critical thinking, conflict resolution and negotiation skills
• Demonstrated ability to work independently and collaboratively with an interdisciplinary team, family members, support networks, and a variety of formal and informal service providers
• Demonstrated commitment to patient centered holistic care
• Excellent time management and stress management skills required
• Fluency in English (verbal and written)
• Computer literacy and basic proficiency is required
• Positive attendance record is required

To pursue this career opportunity, please visit our website: www.trilliumhealthpartners.ca

Internal Candidates who believe they possess the necessary qualifications and experience for this position and who have been in their current position for at least six (6) months are encouraged to apply.

Candidates are selected on the basis of their skill, ability, experience and qualifications.  Where these factors are relatively equal seniority shall govern providing the successful applicant.

Trillium Health Partners’ (THP) is an equal opportunity employer who values the importance of antiracism work and is committed to integrating antiracism, diversity, equity and inclusion best practices throughout THP operations, policies and culture. Therefore, we ask that even if you do not see yourself fully reflected in every job requirement listed on this posting, we still encourage you to reach out and apply. Research has shown that candidates from underrepresented groups often only apply when they feel 100% qualified. We encourage all applicants who are members of groups that have been marginalized on any grounds enumerated under the Ontario Human Rights Code based on race, gender identity or expression, sex, sexual orientation, disability, political belief, religion, marital or family status, age, and/or status as a First Nations, Métis or Inuk/Inuit person to consider this opportunity.

In accordance with the Accessibility for Ontarians with Disabilities Act, 2005 and the Ontario Human Rights Code Trillium Health Partners will provide accommodations throughout the recruitment and selection process to applicants with disabilities.  If selected to participate in the recruitment and selection process, please inform Human Resources of the nature of any accommodation(s) that you may require in respect of any materials or processes used to ensure your equal participation.

All personal information is collected under the authority of the Freedom of Information and Protection of Privacy Act.

Trillium Health Partners is identified under the French Language Services Act.

We thank all those who apply but only those selected for further consideration will be contacted.