Description:
The Transitional Care Coordinator practices in accordance with standards of professional practice and the Osler corporate mission, vision and values that support a model of inter-professional collaboration as a vehicle to facilitate practice culture and support a patient-focused model of care. The Transitional Care Coordinator supports the delivery of a superior care experience to all patients and their families by practicing as an equal member of a core team of skilled professionals working to full scope of practice to ensure that each patient has a comprehensive patient assessment, care plan and timely and effective discharge plan.
Accountabilities:
In collaboration with the inter-professional team, the Transitional Care Coordinator coordinates decision-making for patient transfer and discharge beginning at the point of admission and throughout the hospitalization:
- Screens all admissions for early identification of high-risk discharges (within 24 hours of admission) and documents accordingly
- Conducts a risk assessment using standardized tools and communicates results of the risk assessment to the inter-professional team
- Meets with the patient and family to determine pre-admission physical and mental functioning as it relates to activities of daily living
- Identifies pertinent demographic and health related information, care giver support, community resources, and any previous discharge planning assessments that may impact on the discharge plan
- Within 24 hours of a diagnosis being communicated, collaborates with the patient, family and inter-professional team to develop and implement an effective discharge plan that identifies barriers and solutions
- Initiates, arranges and facilitates case conferences for management of patient care issues such as determining families understanding of discharge clinical care needs, identifying concerns regarding services and co-ordination and identifying short and long-term goals in planning discharge
- Ensures early collaboration with the Home and Community Care Support Servicescase managers on all patients likely to require post discharge support
- Works in collaboration with the Home and Community Care Support Servicescase manager and external agencies to develop and implement the individualized plan of care to facilitate discharge and provide guidance to patients and their families pertaining to relevant community agencies to support their needs
- Collaborates daily (more frequently as required) with the inter-professional team, including the most responsible physician, to uphold and revise as necessary a timely discharge plan
- Documents and communicates discharge plans to the patient, family and the inter-professional team
- Documents assessments and other relevant information in Meditech and at bullet rounds
- Follows the patient's discharge progress through to discharge destination
- Attends bullet rounds and initiates and/or participates in identifying the expected date of discharge and mobilizing the team to work towards a common goal
- Maintains accurate records and statistical information and identifies ALC and actual length of stay information against expected length of stay
- Monitors for extended length of stay beyond the estimated date of discharge and facilitates discussion at bullet rounds to minimize or remove risks and barriers to timely discharge
- Collaborates with other discharge coordinators in developing strategies for extended length of stay at difficult to discharge rounds and communicates strategies to patient care managers
- Attends daily bed management meeting and provides updates related to the patient discharge status, transitional requirementsand repatriation issues
- Provides education, communication and assistance to the patient and family as well as the inter-professional team
- Provides leadership to inter-professional team to assist patients through the health care continuum
- Identifies appropriate spokesperson for the patient if the patient is incapable of making decisions and collaborates with social worker in confirming substitute decision-maker and power of attorney
Qualifications
- Bachelor's Degree in a health related discipline
- Post diploma education/experience in gerontology
- Minimum three to fiveyears recent acute care hospital and community experience
- One year experience in case management, utilization review or equivalent
- Regulated health care professional
- Member in good standing of a professional college
- Minimum one to two years in a leadership position