Overview

The Transition Navigator provides comprehensive, patient-centered transition planning for patients from hospital to the next destination of care. The Transition Navigator is a key member of the interprofessional team. With a focus on the provision of excellence throughout the transition process, the Transition Navigator builds collaborative relationships and strives to deliver an exceptional patient/family experience through the health care journey. The Transition Navigator begins the transition process on patient admission and develops a plan for a transition out of hospital that considers the needs of the patient from a: cultural; financial; social; and spiritual perspective. The Transition Navigator works toward a seamless and sustainable transition, while utilizing their knowledge and understanding of community resources, legislation as it relates to Alternative Level of Care (ALC), Substitute Decision Makers Act, Public Guardian and Trustee and the Public Hospitals Act to reduce patient length of stay and readmissions rates. The Transition Navigator provides education and uses teach-back methodology to ensure health literacy is embedded into the transition process, with follow-up discharge phone calls at regular intervals, to ensure a smooth discharge.

Education

• Bachelors degree in a healthcare field.
• Registration in good standing with relevant professional college.

Qualifications

• 2-3 years recent experience in hospital-based acute care, in a professional field required.
• 2 years recent experience in transition/discharge planning required.
• Working knowledge of community resources, LHIN Home and Community Care, long term care facilities, rehabilitation and palliative care facilities/programs required.
• Experience working with the geriatric population and medical/surgical patients required.
• Demonstrated knowledge and skills in transition/discharge planning, conflict resolution and creative problem solving required.
• Demonstrated working knowledge of legislation including the Substitute Decision Makers Act, Alternative Level of Care, Public Hospitals Act.
• Experience working with the Resource Matching and Referral system and electronic documentation systems.
• Demonstrated ability to prioritize multiple competing workload demands.
• Superior communication and negotiation skills.
• Demonstrated ability to provide resource identification, referral and linking.
• Demonstrated ability to work collaboratively as a member of an interprofessional team.
• Demonstrated ability to build relationships with internal and external partners.
• Demonstrated ability to prioritize and work effectively in a fast paced environment required.
• Demonstrated patient centered philosophy of care provision.
• Good work and attendance record required
• All employees of Michael Garron Hospital (MGH), a division of Toronto East Health Network (TEHN) [formerly Toronto East General Hospital (TEGH)] agree to work within the legislated practices of the Occupational Health and Safety Act of Ontario.
• All employees of MGH are responsible to contribute to a transparent culture of patient and staff safety by adhering to and abiding by patient and staff safety policies and procedures set by MGH.
• All employees are accountable for protecting the psychological health and safety of themselves and their co-workers through adherence to MGH's policies and practices.