Job Description

JOB POSTING # 925394

Position: Integrated Care (IC) Lead (0.6 FTE Part-Time, Float)
Site: Toronto General Hospital and Toronto Western Hospital
Department: UHN@Home
Hours: up to 0.6 FTE, must be available for day shifts, evenings, and on-call on weekdays and weekends. Required to work one in three weekends.
Salary Range: $40.98 to $51.22 per hour
Status: Temporary Part-Time (18 months)

University Health Network (UHN) is looking for an experienced professional to fill the key role of Integrated Care (IC) Lead for Surgery

Transforming lives and communities through excellence in care, discovery and learning.

The University Health Network, where above all else the needs of patients come first, encompasses Toronto General Hospital, Toronto Western Hospital, Princess Margaret Cancer Centre, Toronto Rehabilitation Institute and the Michener Institute of Education at UHN. The University Health Network (UHN), Canadas largest research teaching hospital, brings together over 16,000 employees, more than 1,200 physicians, 8,000+ students, and many volunteers. UHN is a caring, creative place where amazing people are amazing the world.

To inspire, invent and deliver tomorrows care, the Integrated Care Program looks beyond our walls and identifies and integrates the health and well-being services and supports to provide comprehensive care to our patients. The program leverages an integrated delivery model, care team, health record and funding model to optimize patient care outcomes, as well as optimize efficiency and costs for providers. The integrated care team supports patient care and seamless transitions from community to hospital and back to community, including ongoing community management.

If you have a passion for improving patient care and the desire and energy to make change in healthcare please consider joining us.

POSITION SUMMARY:

The Integrated Care Lead Float team member is a critical member of the Integrated Care Program and is the primary contact for patients, essential care partners and the clinical team representing acute care as well as home and community care services. Reporting to the Director UHN@Home, the IC Lead provides leadership for the patient experience by working closely to create one care team to deliver exceptional care and improves the experience and satisfaction of the entire care team. As a leader in a multidisciplinary care team this role focuses on providing comprehensive care to support a patients overall health and well-being including patient-centered navigation, intensive case management and coordination of services to patients as they access care within University Health Network and with partner homecare organizations. As an IC Float Team member the IC Lead will work across care pathways to provide caseload coverage and extra team capacity.

RESPONSIBILTIES INCLUDE:

• Acting as the key lead liaising between patients, the UHN surgical team, community providers, primary care providers, and other providers, to ensure all components of a patients care are provided.
• Developing, supporting and overseeing a patients care path through the various care settings to ensure continuity of care.
• Providing mentorship, coaching and ongoing clinical knowledge transfer to care team members, including home and community partners regarding the IC Program and its patients.
• Provide home visits when required to facilitate patient care and/or in-home training and support for homecare team.
• Working collaboratively with an inter-professional team, family members, support network, and a variety of informal and formal service providers, including home and community care, to ensure ongoing assessment and adjustment to support patient needs.
• Coordinating seamless care transitions through appropriate and effective exchange of knowledge related to respective health conditions and the continuum of services and resources to enhance patient self-management and quality of care.
• Monitoring to ensure that the patient and system level objectives of the bundle of care are met.
• Acting as a subject matter expert to support Program delivery components including: implementation planning, evaluation and innovation and optimization strategies
• Leading ongoing innovation and optimization efforts with regular monitoring of Program data and metrics, synthesizing data to make recommendations or act upon trends or patterns to inform care planning.
• Works within UHNs Safety and Quality policies and procedures.
• Provide cross-coverage of other IC Programs and pathways.

QUALIFICATIONS:

• Undergraduate/Graduate degree in a related health profession.
• Current membership in good standing with applicable/relevant regulatory health professional body in Ontario is required.
• Five (5) years of clinical experience required, experience in a community health setting preferred.
• Five (5) years of recent, related acute care setting experience required.
• Demonstrated experience and competence in areas of patient need relevant to

• Surgery including: thoracic, head and neck, gynecologic oncology, urology, plastics, breast required, orthopedics, vascular, cardiovascular, general surgery, neurosurgery, and/or others, and a willingness to learn or existing knowledge regarding other surgical pathways
• Transplant surgery
• Medicine including: congestive heart failure, chronic obstructive pulmonary disease, chronic and complex older adult care, oncology and a willingness to learn and existing knowledge regarding other patient populations
• Demonstrated experience and competence in case management is preferred.
• Demonstrated recent comprehensive knowledge of community resources and health care delivery systems in acute and community settings is preferred.
• Demonstrated willingness and ability to use new assessment tools and systems as required by the Ministry or in keeping with legislated requirements.
• Demonstrated ability to quickly respond to patients and situations with resourcefulness, flexibility and adaptability is required.
• Excellent interpersonal, communication, organizational and decision-making skills required.
• Demonstrated leadership skills, including problem solving, critical thinking, conflict resolution and the ability to effectively persuade / influence behaviour of others to align with patient care objectives and desired outcomes, are required.
• Demonstrated ability to work both independently and collaboratively with an interdisciplinary team, family members, support networks, and a variety of formal and informal service providers, including home and community care, is required.
• Demonstrated cultural sensitivity awareness and skills to inform and best plan and facilitate coordination of patient care.
• Excellent time management and stress management skills are required.
• Computer literacy and basic proficiency is required with a demonstrated willingness to learn and adapt to new technology.
• Fluency in English (verbal and written) is required.
• A valid drivers license, adequate insurance (personal automobile policy with a minimum $1 million liability limit) and use of a reliable vehicle that qualifies for physical damage coverage is required.

POSTED DATE: October 6, 2023 CLOSING DATE: Until Filled

University Health Network thanks all applicants, however, only those selected for an interview will be contacted.

If you are interested in making your contribution at UHN, please apply on-line. You will be asked to copy and paste as well as attach your resume and covering letter. You will also be required to complete some initial screening questions.

University Health Network