Coordinator - Hospital to Home

Join Northeastern Ontario’s Health Care Leaders!

Health Sciences North is an organization dedicated to being patient and family focused, digitally enabled, and socially accountable, while supporting and developing our people and advancing our academic and research impact for Northeastern Ontario. We pride ourselves on being a learning hospital, providing professional development opportunities for our staff.

Health Sciences North (HSN) is seeking an innovative individual for the position of Coordinator – Hospital to Home. In this role, the successful incumbent will coordinate discharge and transition of patients to the Hospital to Home programs and manage pathways to programs including onboarding and discharge. They will ensure patients are safely discharged or transferred to the appropriate destination.

The ideal candidate will have a minimum of a four (4) year Bachelor’s Degree from an accredited university. We are looking for someone with a minimum of five (5) years’ experience working in health care environment and experience working in a leadership/supervisory role is required. Candidates that possess a Master’s Degree from an accredited university and current Certificate of Registration in good standing with a regulatory college are preferred.

DEPARTMENT OVERVIEW

The Access & Flow department is a diverse team with the primary goal of improving patient flow and care transitions of patients within the organization. Using patient flow data, the department identifies variations in demand and barriers to prompt service access and taking a coordinated approach to guide patients through the healthcare system. The team monitors and provides direction to the Alternate Level of Care (ALC) population at HSN. Part of this initiative is the Hospital to Home Program which supports patients from HSN to community.  

If you enjoy working in a fast-paced, team environment and are looking for a rewarding career opportunity, you are encouraged to view the full job description on the HSN Careers Website.

At HSN/HSNRI, we prioritize the physical and psychological wellness of all our staff through a variety of initiatives, aimed at creating a supportive and engaging workplace. Our Wellness Committee actively promotes health and well-being offering tips and resources to support wellness of our staff. We pride ourselves on recognizing our dedicated team members through Years of Service Celebrations and Excellence in Action Awards, celebrating outstanding achievements across the organization. We host Employee & Medical Staff appreciation events, and celebrations throughout the year, fostering a sense of community. Leadership development training is available to staff as well as an education fund, ensuring. Our people are our number one asset.

HSN provides support through our Employee and Family Assistance Program (EFAP), which is available for all HSN staff and family members regardless of status, position, affiliation, etc.

HSN INCENTIVES

We offer a competitive salary and vacation, extended health and dental benefits, and relocation allowance to assist with moving expenses. In addition, there may be additional monetary incentives available upon hire.

We are proud to participate in the Healthcare of Ontario Pension Plan (HOOPP), offering our valued employees the security and peace of mind that comes with a defined benefit pension plan. We understand the importance of financial well-being and believe that a strong pension, like HOOPP, recognizes our employees and provides a stable foundation for their future as part of the overall compensation package. HOOPP is also a multi-employer pension plan, meaning it can be transferred between many organizations in the province.  Join us and start building a future you can look forward to. For every dollar an employee contributes to HOOPP, the employer (HSN) contributes $1.26, meaning the plan is 55% funded by the employer, and 45% funded by the employee. All employees are eligible to join immediately upon hire.

Interested applicants are asked to apply directly to requisition #7937 by May 14, 2025 at 11:59 pm on the HSN Careers Website at https://careers.hsnsudbury.ca/.

About Sudbury

“Sudbury is a dynamic city that embraces growth and values its residents. With a population of over 166,000 and a regional reach of nearly half a million people within a 160 km radius, Sudbury offers a vibrant community and ample opportunities for personal and professional development. Whether you're considering a move or already planning to relocate, we are committed to supporting you every step of the way. Our strategic location, robust industrial sector, and talented workforce make Sudbury the perfect place to establish and expand your career. Discover a city that welcomes newcomers with open arms and provides a supportive environment for your success.”  For more information regarding our beautiful city or for finding your dream home, rentals or short-term accommodation please visit the following  websites; Newcomers to Sudbury and Find your dream home

KEY FUNCTION:

Coordinate discharge and transition of patients to the Hospital to Home programs. Manage pathways to program including onboarding and discharge. Ensure patients are safely discharged or transferred to the appropriate destination.

REPORTING:    

Under the general direction of the Manager, Access & Flow.

DUTIES:

1. Plan, organize, direct, and evaluate the Hospital to Home programming.
2. Liaise with Agency staff for programming.
3. Support the Home First Operational Directive for HSN.
4. Utilize InterRAI assessment for patient onboarding and service selection.
5. Liaise with Ontario Health at Home, Community Support Services agencies and the Service Provider Organization in patients’ onboarding, discharge and ongoing programming.
6. Participate in the implementation and coordination of a patient-centered care plan with patients, family members, significant others, and the multidisciplinary team for facilitating the patient’s movement through the continuum of care.
7. Provide a link between the hospital community agencies and alternate level of care (ALC) facilities.
8. Review all incoming applications, liaise and establish contact with members of the multi-disciplinary team and appropriate community agencies.
9. Educate hospital staff to the various aspects of the Hospital to Home programs including available resources and aspects of discharge planning.
10. Interact and engage patients and Substitute Decision Makers in initial and continued Home First Philosophy conversations.
11. Act as a clinical resource for acute inter-professional teams by providing information based on Home First Principles and available programming.
12. Attend and contribute to daily meetings (e.g. bed rounds, inpatient bullet rounds, etc.) and be aware of daily bed pressures.
13. Develop strong relationships with physicians and interdisciplinary team members across the organization to develop clear plans and pathways to the Hospital to Home programming.
14. Document action taken and progress in expanse, charting as required.
15. Engage third part participants in improvement initiatives as required.
16. Work with multi-organizational teams to identify and prioritize to further design, develop and/or improve future process and standards of work related to discharge planning and ALC avoidance.
17. Identify patient flow delays and opportunities, and work with Clinical Managers, Clinical Leaders, and Charge Nurses to eliminate delays.
18. Provide updates on Hospital to Home program to Senior Leadership and Ontario Health as required.
19. Provide data output and measures of success for programming.
20. Monitor the flow of patients in and out of HSN beds daily.
21. Implement process improvement initiatives based on lean principles to encourage efficient utilization of HSN resources.
22. Oversee the work of others in compliance with the Occupational Health and Safety Act (OHSA), its regulations, and HSN policies.
23. Determine and align improvement projects with HSN’s Strategic Plan; monitor and adjust to achieve goal outcomes.
24. Participate in the accreditation process and work to ensure that the program and HSN achieve, maintain and continually improve upon their accredited status.
25. Teach, coach and lead staff in the development and monitoring of quality indicators and improvement initiatives.
26. Ensure a safe environment for patients, staff and visitors; investigate, report, debrief and take or direct corrective action as required on incidents.
27. Collaborate with internal and external stakeholders/organizations/community groups to achieve program objectives, integrate and link services and foster partnerships across the continuum of service delivery.
28. Participate in education and training specific to current, relevant federal and provincial health and safety legislation, standards and guidelines.
29. Represent the department or program on various committees and in meetings as required. 
30. Perform other duties as required. 

QUALIFICATIONS

EDUCATION AND TRAINING: 

1. Minimum of a four (4) year Bachelor’s Degree from an accredited university.
2. Master’s Degree from an accredited university is preferred.
3. Current Certificate of Registration in good standing with a regulatory college is preferred.
4. Ministry of Labour “Worker Health and Safety Awareness in 4 Steps” training certificate is required.

EXPERIENCE: 

1. Minimum of five (5) years’ experience working in health care environment.
2. Experience working in a leadership/supervisory role is required.
3. Experience in using utilization management principles and length of stay management strategies is preferred.
4. Experience with Home First Implementation is preferred.
5. Training or recent experience with project management is preferred.
6. Experience working with data management software is preferred.

KNOWLEDGE/SKILLS/ABILITIES: 

1. Demonstrated knowledge of risk assessment tools (i.e. Appropriate Use of Antipsychotics (AUA), Barthel Index, Blaylock, and InterRAI Assessment).
2. Demonstrated knowledge of health research and/or best practice guidelines in discharge planning and ALC Avoidance.
3. Demonstrated knowledge of the Alternate Level of Care (ALC) Leading Practices Guide.
4. Demonstrated knowledge of the Transitions Between Hospital and Home Quality Standards.
5. Demonstrated knowledge of the Home First Guiding Principles.
6. Demonstrated knowledge of key system constraints based on analysis of data and trends.
7. Demonstrated knowledge of the health care system and community resources.
8. Demonstrated ability to identify and implement data indicators to continue quality improvement.
9. Demonstrated clinical assessment and conflict management skills.
10. Demonstrated time management, prioritization, organizational, and problem-solving skills.
11. Demonstrated ability to coach, advise and teach others using the principles of adult learning.
12. Demonstrated training, experience or utilization of quality improvement methodology for process improvement.
13. Demonstrated ability to independently identify issues, plan improvements, measure success and continue improvement.
14. Demonstrated knowledge of relevant legislation and principles of management, hospital committee structure, conflict management and resolution, system needs analysis and organizational assessment.
15. Ability to use tact and discretion in dealing with health care providers and employees.
16. Demonstrated excellent computer skills with proficiency in Microsoft Office software (e.g. Word, Excel, Power Point and Outlook) and patient information systems.
17. Demonstrated superior interpersonal and communication skills, both written and verbal.
18. Demonstrated commitment to the safety of co-workers and patients.

PERSONAL SUITABILITY: 

1. Successful vulnerable sector check is required.
2. Demonstrated ability to work in a fast-paced environment.
3. Demonstrated commitment to ongoing professional development.
4. Demonstrated professionalism in dealing with confidential and sensitive issues.
5. Demonstrated positive work record and excellent attendance record.
6. Ability to meet the physical and sensory demands of the job.
7. Ability to travel between local sites.

Selection Process:  Candidates will be selected for this position on the basis of their skill, ability, experience and qualifications as identified in the resume and completed Application Form submitted. The Hospital reserves the right to conduct a formal interview where required.
 

Health Sciences North is committed to providing accommodations to applicants with disabilities to enable their participation in the recruitment, assessment, selection and hiring stages of employment.

HSN THANKS ALL APPLICANTS.
ONLY THOSE SELECTED FOR INTERVIEWS WILL BE CONTACTED.
WE WILL NOT ACCEPT APPLICATIONS AFTER THE CLOSING DATE AND TIME.