Job Description

Join the YourCare@Home program, where CBI Home Health supports the Ottawa Hospital by providing outstanding, person-centered care to help patients achieve the best possible outcomes as they return home. As part of an integrated team, CBI Home Health team members work closely together to restore function, independence, confidence, and social connection. CBI Home Health provides training and support so that team members can deliver health care in the home that meets best practice standards and makes a meaningful difference to both patients and the health care system. Come see what home care can be like when you can deliver the best care to meet patient needs.



As a

Transitional Lead

in CBI Home Health's specialized, integrated care programs, you will play a pivotal role in shaping seamless, patient-centered transitions from hospital to home, ensuring every individual receives the right care at the right time. Partnering closely with hospital teams, community partners, and families, you'll create comprehensive care plans that not only support safe discharges but also empower patients to thrive sustainably at home.



Serving as the primary point of contact, you'll be a trusted guide for patients and their families--providing consistent check-ins, home visits, and ongoing support to ensure their goals are being met. Collaborating with an interdisciplinary care team, you'll identify solutions for emerging challenges and proactively monitor patient progress. In this dynamic role, you'll also track and analyze service utilization, documentation, and key performance metrics (KPIs) to continuously improve care delivery. Your keen insights and innovative thinking will drive quality improvements and uncover new growth opportunities to keep our programs on the leading edge of care.

What we offer:

Competitive compensation Paid sick days, vacation, orientation, and training Comprehensive benefits plan for you and your family Mobile technology and training provided (cell phone and tablet) Easy access to managers and interdisciplinary team to support you Access to 24/7 support, no matter where you are Supportive onboarding program, mentorship, and ongoing learning and development to continuously advance your knowledge and skills Opportunities to grow your career within CBI Home Health's national network

Key Responsibilities:

Primary contact for operational partners (hospital, community support services, etc.) involved in transition planning of patients. Participate and contribute to daily hospital huddles related to new referrals, planned discharges, and problem-solving. Participate in patient and program-related meetings as required. Establish and foster positive partner relationships with key internal and external stakeholders. Ensure that CBI Home Health care team members have the appropriate and timely information for effective care delivery and transitions. Work with the hospital partners to identify and assess potential patient referrals. Create a transitional care plan to support an effective transition out of the hospital, identifying and coordination services and support required for a sustainable transition home. Work closely with CBI Home Health team to coordinate services and support to meet patient needs upon admission and ongoing. Lead/participate in patient care conferences to review goal progression, service gaps, and barriers to discharge. Lead/participate in the development of proactive and suitable community transition care plan involving the patient and circle of care. Regularly communicate with and involve primary care providers in the patient's care plan, goals and progress. Effectively communicate with patients and families throughout transitions: discharge from hospital and transition to community. Ensure effective collaboration and knowledge transfer with CBI Home Health resources to coordinate services and ensure a smooth transition. Engage the CBI Home Health interdisciplinary team to problem-solve and identify innovative solutions to situations. Monitor and ensure appropriate documentation, clinical outcome measures and metrics are completed for each patient as per CBI Home Health program standard. Monitor data and documentation integrity and identify any gaps or issues accordingly. Contribute to the collection and analysis of data and metrics for reporting purposes. Monitor program service utilization and proactively identify any concerns or risks. Identify any trends or opportunities for program improvement and escalate them accordingly with suggested solutions. Participate and lead in program evaluation activities as required. Coordinate and apply patient and caregiver experience surveys for timely experience information gathering & analysis as per program standards. Coordinate and apply staff experience surveys as per program standards.

What you will need to be successful:

Regulated Health Professional, registered and in good standing with respective College. Preference to RN, Occupational Therapist, and Physiotherapist. Postgraduate education such as a Master's level degree or advanced university/ executive training considered an asset 5 to 7 years' experience in a general management role in a service-focused organization, home and community care experience preferred 2-3 years' experience in your regulated health profession, preferably in Nursing, Occupational Therapy, or Physiotherapy Strong clinical skill set and demonstrated commitment to best practice care Ability to lead teams and individuals to achieve results Demonstrated success with program evaluation and improvement Experience with clinical program monitoring Excellent written and verbal communication skills High degree of professionalism and patient/family-focused care Be a team player and be highly collaborative Strong computer literacy with various applications and programs Demonstrated clinical leadership & ability to lead discussions and collaboration Excellent assessment and coordination skills Demonstrated ability to work within an interdisciplinary team Strong organization skills and able to prioritize/ multi-task in a fast-paced environment Clear criminal record check with vulnerable sector screening A valid driver's license, access to a reliable insured vehicle, and the ability to travel within the Region Ability to communicate in French or other languages is considered an asset

Join us at CBI Home Health - Because Your Care Matters.

To learn more about CBI Home Health, please visit www.cbihomehealth.ca



CBI Home Health is committed to providing a diverse, equitable, and inclusive workplace where everyone feels safe and accepted as their authentic selves. We actively seek qualified candidates who share our commitment to equity and inclusion and contribute to the diversification of ideas and perspectives that help us innovate and provide the best possible care to our clients.



We are committed to fostering a positive experience for all Indigenous applicants whether you're First Nations (status or non-status), Inuit or Metis and welcome applications from all individuals regardless of race, colour, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, veteran status, or any other characteristics that make each of us different.



In accordance with the Ontario Human Rights Code, Accessibility for Ontarians with Disabilities Act, and CBI Home Health Policies on Accommodation, a request for accommodation will be accepted as part of our hiring process. Please inform your recruiter if you have any accommodation requests.



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