Transition to Home Planner (2017-178)

SHIFT: Days (0800-1600); including weekends

The Transition to Home Planner will provide consultation for patients with complex needs in planning for discharge while supporting the patient experience and the patient plan of care. The Transition to Home Planner provides admission avoidance support to the ED and/or inpatient units to reduce hospital length of stays and repeat admissions.The Transition to Home Planner will work collaboratively with patients, families and the care team to identify possible barriers to return to home and to develop a safe and supportive discharge plan.Priority will be given to patients who are experiencing increasing frailty and are high risk for medical and psychosocial issues.

QUALIFICATIONS:

• Exhibit the core values of CGMH: Caring, Accountable, Respect, Excellence, Adaptable, Teamwork
• University, College or Diploma in Health related profession or equivalent
• Current registration with any regulated health care professional college in ON
• Experience working with discharge planning/case & bed flow management in an acute care setting is preferred
• Ability to organize patient care demands and set priorities while working independently and collaboratively with all members of the health care team including the patients and families
• Demonstrated assessment, health promotion, health teaching skills, critical thinking, problem solving and decision making skills
• Excellent communication, organizational and interpersonal skills with the ability to perform duties in a professional and courteous manner
• Excellent customer service demeanour
• Physically able to perform the essential duties of the role
• Excellent attendance/performance record
• Committed to professional growth & development
• Committed to maintaining confidentiality
• Education in gerontology and/or chronic disease management an asset
• Familiarity with Meditech is an asset

DUTIES:

• Provide consultation to identify barriers to return to home of ‘patients in the ED and on the inpatient unit to initiate a safe discharge plan on admission in order to reduce admission LOS.
• Support ‘Right Care-Right Place’ providing transitional care to patient and families while facilitating patient flow processes including surge management
• Foster the ‘Home First’ philosophyand system/regional initiatives
• Work with our internal Allied Healthcare Professionals and Community Agencies to provide appropriate supports in the community to ensure safe and timely patient transitions