Manager, Integrated Transitions in Care

  • Humber River Hospital
  • Sep 13, 2018
Full time Manager

Job Description

Position Profile

Lead the team that delivers care and support for areas of acute and ALC patient care with a focus on discharge planning, transitions in care and psychosocial support. As the Manager, you will ensure there is ongoing improvements for patient flow, quality outcomes and operational performance in an efficient manner and in collaboration with community partners.

At Humber River Hospital, we are currently seeking a Manager, Integrated Transitions in Care. The primary focus of this role is to ensure seamless and supported transitions along the continuum of care including acute, post-acute and community. The Manager will lead the implementation, operation and ongoing evaluation of the Assess and Restore program across inpatient and outpatient care settings. The Manager, Integrated Transitions in Care will lead the operation and ongoing evaluation of the Geriatric Outreach Team and Nurse Lead Outreach Team.

Are you a passionate Clinical Manager with experience dealing with integrated transitions in care? Are you a dedicated professional who enjoys working with the acute and ALC patient population? If you answered yes, we invite you to read the details below and apply to this exciting career opportunity at Humber River Hospital.

Reporting Relationship: Program Director, Seniors Care  

Hiring Salary Range: $95,833 - $107,817

Position Responsibilities:

  •  Facilitate early identification and timely designation of ALC for patients and all associated escalation processes.
  • Support the development of the social work role to maximize the quality outcomes and experience for patients, families, staff and physicians.
  • Lead inpatient discharge planning operations and initiatives, including joint discharge rounds, Long term care (LTC) rounds, iPlan implementation and evaluation.
  • Lead quality improvement initiatives for discharge planning and integrated transitions in care.
  • Monitor and evaluate daily operational clinical performance to optimize the quality of patient care delivery in alignment with organizational goals and priorities.
  • Develop and monitor variances in unit operating budget in collaboration with the Director and Decision Support Services (DSS).
  • Coordinate discharge planning to ensure all patients are referred to the most appropriate services for their clinical needs, and proactively identify and resolve barriers to discharge for patients.
  • Collaborate with inpatient managers to identify process improvement strategies to improve the current inpatient system and reduce patient length of stay (LOS).
  • Liaise with community and long term care hospital (LTCH) partners.
  • Lead Joint Discharge Rounds (JDR) and bullet round process.
  • Manage ALC escalation and data.
  • Manage daily clinical operations, and evaluate operational performance against department and organizational goals and priorities.
  • Identify patients that can be transferred to the ALC unit.
  • Lead Joint Discharge Rounds, Complex Discharge Rounds and LTC rounds.
  • Develop and implement policies and educational materials.
  • Lead and participate in operational committees, both internal (e.g. Pharmacy Therapeutics, Safe Medication Practices), and external (e.g. professional clinical and operational practice networks including Regional Geriatric Program of Toronto).
  • Participate in LHIN initiatives such as the ALC working group.


  • Regulated Health Care Professional in good standing with respective health professional regulatory body in Ontario
  • A Master’s degree in a clinical discipline, Health or Business Administration required
  • Basic Cardiac Life Support (BLCS) Certification
  • A minimum of (5) five years of clinical experience in an acute care hospital
  • A minimum of (3) three years management experience with direct people management responsibilities.
  • Exceptional analytical and information-seeking skills that contribute to effective decision-making and strategic planning and execution of action plans that deliver results and motivate individuals for greater performance excellence
  • Ability to work with a diverse group of leaders and stakeholders with demonstrated success in moving key stakeholders to positive resolution and to facilitate and coach clinical areas on change initiatives
  • Experience managing in a multi-union environment
  • Track record of delivering exceptional clinical practice, efficiency and patient care
  • Track record for creating a quality and safety culture and means for monitoring and communicating results that is meaningful to team members and inspires continuous improvement
  • Self-directed, courageous, and highly motivated with excellent interpersonal and communication skills
  • Experience managing competing demands in a fast-paced, multi-site, multi-disciplinary health care environment

Why Humber? Why Now?

Humber River Hospital is on an exciting transformation journey of redefining patient care as we leverage the most advanced technologies to enhance all aspects of delivering high-quality, safe care. We continue to build a people-centered workplace with excellent staff and physician engagement by hiring passionate, diverse and inclusive healthcare professionals. People who care and live our values of CompassionProfessionalism and Respect. People who are committed to making a positive difference.

We are a Studer Group hospital, focused on building our evidence-based leadership practice and hardwiring a culture that WOWs.

Why? Because at Humber River Hospital, we know it’s our people and our ability to innovate that allows us to consistently deliver a great patient experience and the best quality outcomes. After all, we are the hospital that believes exceptional care...healthier community.

To express your interest in this exciting opportunity, please  complete the online application in confidence at

This description has been designed to indicate the general nature and level of work performed by the employee within this position. However, the actual responsibilities, duties, qualifications and experience may vary. Employee may perform other related duties as required to meet the ongoing needs of the organization. Information contained in this job posting/description is subject to change.

Note: This is a non-union position

Humber River Hospital is committed to inclusion and diversity. We believe that diversity drives our culture of innovation. By bringing together a variety of different perspectives, it fuels our creative thinking, generates new ideas and creates solutions designed to address tomorrow's healthcare challenges today. We take pride in providing professional development and career advancement opportunities for our employees including minorities, women, veterans and individuals with physical and developmental disabilities. We also provide accommodation to applicants and all of our employees - from hire to retire.

Let us know what we can do to help you be successful during your recruitment experience at Humber River Hospital.

Connect With Us!

Apply now at   Reference Job number (2018-6173)

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