Transitions Care Lead

The Acute Care Transitions Program ensures seamless, compassionate care as patients move from hospital to home. Designed to support both patients and their families, the program connects individuals with community-based healthcare providers, social support services, primary care and acute care teams. Together, they create personalized plans that improve outcomes and ease the transition to home.

Remote role

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!

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.

Why join our team?

• Competitive compensation. Our Total Rewards package includes a competitive salary, group benefits, RRSP pension, on demand pay and exclusive perks/discounts available only to SE Health staff
• Meaningful Impact – As a Social Enterprise, your work directly supports improving lives across Canada. Your voice matters, and innovation is encouraged.
• Growth & Development – Access tuition assistance, training, and career advancement opportunities across our growing organization.

• 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,…