Humber River Hospital
Build your career at the hospital that’s building for the future
Humber River Hospital is committed to revolutionizing patient care for our diverse community. We’re looking for exceptional individuals to join our great team: people who share our passion to deliver excellent, patient-focused, expert care. The Hospital is formally affiliated with both the University of Toronto and Queen’s University.
We have an exciting opportunity for two (2) Full Time SCOPE/LTC+ Navigator to join our team within Integrated Health Systems & Partnerships at Humber River Hospital. This department works collaboratively with internal departments, community partners, primary care, agencies, Ontario Health and the Ministry of Health to plan and build an Integrated Health System to improve the health of our community. SCOPE (Seamless Care Optimization the Patient Experience) is a quality improvement collaboration between the hospital and primary care providers (PCPs) located in North West Toronto. The SCOPE service is a virtual inter-professional team that facilitates greater access to hospital-based interdisciplinary resources and other specialists care. SCOPEaims to reduce avoidable ED visits and hospital re-admissions for patients in need. LTC+ (Long Term Care +) is a virtual care model that provides direct access to a suite of services including real-time access to virtual GIM consultations, specialist care and community resources for the partner LTC homes in North West Toronto. LTC+ aims to deliver the best care possible to residents in LTC homes to avoid unnecessary transfers to hospital and improve access to outpatient clinics/resources.
Reporting to the Manager, Family Medicine Teaching Unit and Integrated Care Services , the SCOPE/LTC+ Navigator will coordinate and assist physicians in primary care and in Long Term Care Homes in navigating SCOPEservices, providing centralized access to hospital and community services, with follow-up on status of referrals, results, and consults. This role supports timely access, ensures navigator to appropriate resources, and reduced ED visits as patients are proactively connected to the right level of care
Availability (2 positions):
Days. Monday – Friday (subject to change); some weekend work may be required.
Afternoons/Evenings. Monday – Friday (subject to change); some weekend work may be required.
Union: Non Union
RESPONSIBLITIES
Play a leadership role in the implementation, monitoring, and evaluation of the SCOPE and LTC+ program
Participate in the implementation, monitoring, and evaluation of the SCOPE/LTC+ program
Participates in internal and external committees/working groups
Enhance work-flow and communication pathways between hospital, primary care and community care by identifying barriers to care and work towards creating new care pathways to promote and optimize seamless care for the client.
Advocate for, and contribute to, the establishment of organizational structures and resources to support the growth of SCOPE and LTC+ in keeping with the direction and priorities of the organization
Advocate to identify gaps in services, needed for individualized program consideration 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
Respond to all calls and emails made to SCOPE/LTC+ Navigation Hub by the PCPs, LTC physicians and Nurse Practitioners and their administrative assistants
Assist Primary Care Providers in the community and LTC with system navigation, referrals to specialists, and resources in the community, and other appropriate community, clinical and specialized supports to address patient health concerns.
Ensure seamless navigation of existing services; triage and forward referrals to appropriate SCOPE/LTC+ contact (i.e. Internist, Home and Community Care Coordinator, Imaging, Outpatient Clinics)
Collaborate with the health care team to improve patient care as they transition through the health care system
Collect relevant patient information required for assessment and database entry (Patient Name, DOB, HC#)
Understand and clarify PCP primary concerns and request for support
Work collaboratively and in relationship with the inter-professional team while role modelling relationship centered care
Use concepts from complexity thinking and relational inquiry when in relationship with others.
Collect Data for research evaluation for each referral – Database Entry forms to be completed with each referral and submitted to the evaluation team on a weekly basis
Review available/relevant information from Meditech (EMR) to determine assessment and care planning
If client is an existing or former clinic patient, will re-connect with staff to communicate PCP concerns and request for assessment
This includes the clarification of referral criteria and identification of the resource that will best suit the health care need
Improve communication and collaboration between consultants and primary care services by assisting PCP staff in the compilation of referral packages and follow-up of referrals
Provide PCP or PCP staff with clinic/referral information
Navigate hospital clinics and resources that will assist PCP with managing client medical, functional, cognitive, psychosocial conditions
Direct requests for Internal medicine consultations or medical work-ups to SCOPE/LTC+’s Internist-On-Call
Coordinate care delivery and the development of individualized care plans with the persons internal and external stakeholders including liaising with outside agencies to facilitate seamless care for persons across sectors – primary, acute and community care
REQUIREMENTS
Bachelor of Science in Nursing
Masters in Nursing or a related discipline
Current registration and membership in good standing with the College of Nurses of Ontario
Minimum of 3 years of experience within acute care and/or primary/community care
Written and verbal communications with ability to explain and provide necessary information to patients, family members, physician and/or any stakeholders
Experience working within an interprofessional team environment as well as independently
Experience working with older patients with complex needs
Demonstrated computer skills using MS Office (Outlook, Word, Excel, PowerPoint, Visio, etc.)
Database management skills preferred with strong written and oral interpersonal skills
Understand and appreciate primary care challenges
Respectful, responsive communication system, able to communicate with front-line staff, primary care providers and specialist offices
Evidence of program design and resources development skills, including knowledge of evaluation methodologies
Highly Organized with the ability to multitask
Strong work ethic - committed to task completion and follow through
Ability to be flexible and adapt to a changing environment assuming responsibility for own learning
Excellent team player
Excellent attendance and discipline free record required.
We thank all candidates that apply, only qualified candidates will be contacted for an interview
Humber River Hospital is an equal opportunity employer and we will accommodate your needs under the Ontario Human Rights Code. Upon individual request, hiring processes will be modified to remove barriers to accommodate those with disabilities. Should any applicant require accommodation through the application, interview or selection processes, please contact the Human Resources Department for assistance.
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 Compassion , Professionalism and Respect . People who are committed to making a positive difference.
We are a Studer Group hospital, focused on building our evidence-based 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 .
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 th Save is job posting/description is subject to change.
This position will be filled in accordance to the OPSEU 590 collective agreement.
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.
Please be advised that in order to be eligible for employment at Humber River Hospital, all new hires must have received the full series of a COVID-19 vaccine or combination of COVID-19 vaccines approved by Health Canada (e.g., two doses of a two-dose vaccine series, or one dose of a single-dose vaccine series); AND have received the final dose of the COVID-19 vaccine at least 14 days prior to the hired employee’s first date of employment Medical exemptions or any other kind of requested exemption based upon the Hospital’s obligations pursuant to the Ontario Human Rights Code will be considered on a case-by-case basis
Build your career at the hospital that’s building for the future
Humber River Hospital is committed to revolutionizing patient care for our diverse community. We’re looking for exceptional individuals to join our great team: people who share our passion to deliver excellent, patient-focused, expert care. The Hospital is formally affiliated with both the University of Toronto and Queen’s University.
We have an exciting opportunity for two (2) Full Time SCOPE/LTC+ Navigator to join our team within Integrated Health Systems & Partnerships at Humber River Hospital. This department works collaboratively with internal departments, community partners, primary care, agencies, Ontario Health and the Ministry of Health to plan and build an Integrated Health System to improve the health of our community. SCOPE (Seamless Care Optimization the Patient Experience) is a quality improvement collaboration between the hospital and primary care providers (PCPs) located in North West Toronto. The SCOPE service is a virtual inter-professional team that facilitates greater access to hospital-based interdisciplinary resources and other specialists care. SCOPEaims to reduce avoidable ED visits and hospital re-admissions for patients in need. LTC+ (Long Term Care +) is a virtual care model that provides direct access to a suite of services including real-time access to virtual GIM consultations, specialist care and community resources for the partner LTC homes in North West Toronto. LTC+ aims to deliver the best care possible to residents in LTC homes to avoid unnecessary transfers to hospital and improve access to outpatient clinics/resources.
Reporting to the Manager, Family Medicine Teaching Unit and Integrated Care Services , the SCOPE/LTC+ Navigator will coordinate and assist physicians in primary care and in Long Term Care Homes in navigating SCOPEservices, providing centralized access to hospital and community services, with follow-up on status of referrals, results, and consults. This role supports timely access, ensures navigator to appropriate resources, and reduced ED visits as patients are proactively connected to the right level of care
Availability (2 positions):
Days. Monday – Friday (subject to change); some weekend work may be required.
Afternoons/Evenings. Monday – Friday (subject to change); some weekend work may be required.
Union: Non Union
RESPONSIBLITIES
Play a leadership role in the implementation, monitoring, and evaluation of the SCOPE and LTC+ program
Participate in the implementation, monitoring, and evaluation of the SCOPE/LTC+ program
Participates in internal and external committees/working groups
Enhance work-flow and communication pathways between hospital, primary care and community care by identifying barriers to care and work towards creating new care pathways to promote and optimize seamless care for the client.
Advocate for, and contribute to, the establishment of organizational structures and resources to support the growth of SCOPE and LTC+ in keeping with the direction and priorities of the organization
Advocate to identify gaps in services, needed for individualized program consideration 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
Respond to all calls and emails made to SCOPE/LTC+ Navigation Hub by the PCPs, LTC physicians and Nurse Practitioners and their administrative assistants
Assist Primary Care Providers in the community and LTC with system navigation, referrals to specialists, and resources in the community, and other appropriate community, clinical and specialized supports to address patient health concerns.
Ensure seamless navigation of existing services; triage and forward referrals to appropriate SCOPE/LTC+ contact (i.e. Internist, Home and Community Care Coordinator, Imaging, Outpatient Clinics)
Collaborate with the health care team to improve patient care as they transition through the health care system
Collect relevant patient information required for assessment and database entry (Patient Name, DOB, HC#)
Understand and clarify PCP primary concerns and request for support
Work collaboratively and in relationship with the inter-professional team while role modelling relationship centered care
Use concepts from complexity thinking and relational inquiry when in relationship with others.
Collect Data for research evaluation for each referral – Database Entry forms to be completed with each referral and submitted to the evaluation team on a weekly basis
Review available/relevant information from Meditech (EMR) to determine assessment and care planning
If client is an existing or former clinic patient, will re-connect with staff to communicate PCP concerns and request for assessment
This includes the clarification of referral criteria and identification of the resource that will best suit the health care need
Improve communication and collaboration between consultants and primary care services by assisting PCP staff in the compilation of referral packages and follow-up of referrals
Provide PCP or PCP staff with clinic/referral information
Navigate hospital clinics and resources that will assist PCP with managing client medical, functional, cognitive, psychosocial conditions
Direct requests for Internal medicine consultations or medical work-ups to SCOPE/LTC+’s Internist-On-Call
Coordinate care delivery and the development of individualized care plans with the persons internal and external stakeholders including liaising with outside agencies to facilitate seamless care for persons across sectors – primary, acute and community care
REQUIREMENTS
Bachelor of Science in Nursing
Masters in Nursing or a related discipline
Current registration and membership in good standing with the College of Nurses of Ontario
Minimum of 3 years of experience within acute care and/or primary/community care
Written and verbal communications with ability to explain and provide necessary information to patients, family members, physician and/or any stakeholders
Experience working within an interprofessional team environment as well as independently
Experience working with older patients with complex needs
Demonstrated computer skills using MS Office (Outlook, Word, Excel, PowerPoint, Visio, etc.)
Database management skills preferred with strong written and oral interpersonal skills
Understand and appreciate primary care challenges
Respectful, responsive communication system, able to communicate with front-line staff, primary care providers and specialist offices
Evidence of program design and resources development skills, including knowledge of evaluation methodologies
Highly Organized with the ability to multitask
Strong work ethic - committed to task completion and follow through
Ability to be flexible and adapt to a changing environment assuming responsibility for own learning
Excellent team player
Excellent attendance and discipline free record required.
We thank all candidates that apply, only qualified candidates will be contacted for an interview
Humber River Hospital is an equal opportunity employer and we will accommodate your needs under the Ontario Human Rights Code. Upon individual request, hiring processes will be modified to remove barriers to accommodate those with disabilities. Should any applicant require accommodation through the application, interview or selection processes, please contact the Human Resources Department for assistance.
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 Compassion , Professionalism and Respect . People who are committed to making a positive difference.
We are a Studer Group hospital, focused on building our evidence-based 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 .
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 th Save is job posting/description is subject to change.
This position will be filled in accordance to the OPSEU 590 collective agreement.
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.
Please be advised that in order to be eligible for employment at Humber River Hospital, all new hires must have received the full series of a COVID-19 vaccine or combination of COVID-19 vaccines approved by Health Canada (e.g., two doses of a two-dose vaccine series, or one dose of a single-dose vaccine series); AND have received the final dose of the COVID-19 vaccine at least 14 days prior to the hired employee’s first date of employment Medical exemptions or any other kind of requested exemption based upon the Hospital’s obligations pursuant to the Ontario Human Rights Code will be considered on a case-by-case basis
