Job Description

Alexandra Hospital, Ingersoll and Tillsonburg District Memorial Hospital are actively seeking applicants for an Integrated Hospital 2 Home Patient Navigator.


Reporting to Clinical Services Program at, the Alexandra Hospital Ingersoll (AHI) and Tillsonburg District Memorial Hospital (TDMH), the Hospital to Home (H2H) Navigator in collaboration with the patient, family/supports, physician, and members of the clinical team will identify eligible patients for the Hospital to Home Program. The Navigator acts as the liaison between the AHITDMH hospital teams, the home care service provider, and the primary care physician. Navigator will physically work between both sites, in accordance with established standards, professional requirements and as a member of the multidisciplinary health care team the H2H Patient Navigator provides administrative and clinical support to all staff in a supportive, empowering manner while facilitating the effective and efficient movement of admitted patients through the hospital system


The H2H Patient Navigator practices in accordance with AHITDMH corporate mission, vision and values providing program oversight and ensuring identified patients have a comprehensive eligibility assessment, and a high-quality patient and family-centered transition care plan prepared to enable the safe and effective delivery of care in the patient's home environment.


The aim of the program is to transition medically stable patients who have restorative potential back home with a clear, comprehensive bundled care plan of professional and personal support services.

Key Responsibilities

Collaborate with Service Provider Organization (SPO), community care partners and respective leadership to gain appropriate insights to support the creation of a safe and feasible transition care plan that will achieve the patients' care goals within the appropriate amount of time Respond to all H2H referrals and emails made to H2H program. Collect relevant patient information required for assessment and database entry. Complete the referral for community services, prepare the 72-hour care plan with the patient/family, health care team and service provider. Attend patient discharge rounds daily (Inpatient and Emergency Department). Collect Data for evaluation for the H2H program Review available/relevant information from Electronic Medical Record to determine assessment and care planning Enhance workflow 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 transitions for the client. Attend SPO huddles weekly and monitor patient progression through the H2H program. Support the delivery of care, while providing a great patient care experience, receiving and responding to feedback, in collaboration with leadership and service provider partners, as applicable

Qualifications Required

Member of a professional college and in good standing Five (5) years practical and related clinical experience. Knowledge and experience in accessflow, discharge planning and case management Proof of Basic Life Support for Health Care Providers Experience with Microsoft Office Experience with Cerner Experience working within an inter-professional team environment as well as independently and autonomously. Experience working with older patients with complex medical needs required. Must be flexible and able to adapt to changing environments. Understanding of community resources and programs available to support seniors within our communities. Excellent interpersonal and decision-making skills. Strong organizational skills. Ability to adapt to a changing environment and assume responsibility for own learning. Demonstrated leadership skills and ability. Computer literacy required - database management skills preferred. Recent satisfactory performance and attendance records. Proven ability to manage multiple tasks and meet tight deadlines. Excellent written and oral communication skills, with the ability to present complex information clearly. Familiarity with industry best practices and trends in program management. Strong problem-solving skills and the ability to think critically and strategically. Experience with tools and methodologies for data collection, analysis, and reporting. Proficient with computer systems such as email, MS Word, MS Excel, MS PowerPoint, and other project management tools. Demonstrated experience working with financial decision support systems, electronic health records, and administrative information systems. Safety (patient, workerworkplace) is AHI and TDMH Corporate Priority. The successful applicant will demonstrate good stewardship in the identification, reporting and mitigation of unsafe acts or conditions.

Other Pertinent Conditions:

Salary as per the Non-Union Salary Schedule ($47.09 per hour to $55.09 per hour)
Must be available to work all shifts as required, which may include weekends, statutory holidays, days, evenings and night shifts. Hours are subject to change based on operation needs of the hospital.


If you meet the above qualifications and are interested in applying for the position, please click on

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and submit a resume detailing your qualifications.


We thank all applicants, however, only those being considered for an interview will be contacted. Alexandra Hospital, Ingersoll (AHI) and Tillsonburg District Memorial Hospital (TDMH) is an equal opportunity employer, and we value the importance of diversity and dignity in the workplace. We are committed to developing inclusive, barrier-free recruitment and selection processes and work environments. If you are contacted by either hospital regarding a job opportunity, please advise prior to the interview if you require accommodation and we will work with you to make appropriate arrangements.