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SE Careers

Transitions Care Lead

Location: Richmond Hill
Job Code: 18336
Employment Status: Full time
# of openings: 1


About the Role

This is a new and exciting leadership role within hospital transitional programs working with closely with hospitals to transition and reintegrate clients back into the community.  As a member of the Acute Transitions leadership team, you are passionate about informing and shaping the transition from hospital to home and being at the forefront of healthcare innovation in Canada.

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.

Please note this a full-time 6 month contract

Main 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


  • 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 skills in Microsoft Office (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.
  • Flexibile availablity, working day time hours and evenings up to 8pm including weekends

About SE Health  
SE Health (Saint Elizabeth Health Care) is a social enterprise applying our knowledge, vision and drive to forever impact how people live and age at home, today and into the future. As a not-for-profit organization with Canadian roots and 110 years of expertise, we bring quality excellence and innovation to home care, seniors lifestyle and family caregiving. Through our team of 9,000 Leaders of Impact, we deliver 20,000 care exchanges daily, totaling 50 million in the last decade alone. In 2019 we were honored to be recognized by Forbes as one of Canada's Best Employers. 

Saint Elizabeth is committed to the success of all its employees. If you feel you need accommodations because of illness or disability, please do not hesitate to contact Human Resources at at your earliest convenience.

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