SCOPE/LTC+ Navigator

Humber River Health•Toronto, ON

1d•CA$53 - CA$66•Onsite

About The Position

Humber River Health is seeking a temporary full-time SCOPE/LTC+ Navigator to join their Integrated Health Systems & Partnerships department. This role is crucial in collaborating with internal departments, community partners, primary care, agencies, Ontario Health, and the Ministry of Health to build an Integrated Health System. The SCOPE program is a quality improvement initiative between the hospital and primary care providers in North West Toronto, utilizing a virtual inter-professional team to improve access to hospital-based resources and specialist care, aiming to reduce avoidable ED visits and hospital re-admissions. The LTC+ program is a virtual care model providing direct access to services like virtual GIM consultations, specialist care, and community resources for partner Long Term Care homes in North West Toronto, with the goal of delivering optimal care to residents and avoiding unnecessary hospital transfers. The position is for a temporary duration until January 3, 2027, with potential for change, and involves working days/afternoons with possible weekend work.

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.

Responsibilities

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