Integrated Care Lead - University Health Network, Toronto

Role overview

The Integrated Care Lead is a critical member of the UHN at Home Program and serves as 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 Manager of UHN at Home at Toronto Western Hospital, this on-site administration role provides leadership for the patient experience by working closely to create one care team that delivers exceptional care and improves overall satisfaction. This temporary full-time position requires 37.5 hours per week, primarily on day shifts with required availability for on-call duties, day, afternoon, evening rotations, and weekends.

Your impact

In this multidisciplinary care team leadership role, you will focus on comprehensive care to support patient health and well-being through patient-centred navigation, intensive case management, and service coordination. Your daily duties 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 patient’s care are provided.
• Developing, supporting and overseeing a patient’s 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 in-person and/or remote 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 UHN’s Safety and Quality policies and procedures.
• Provide cross-coverage of other IC Programs and pathways.

Skills and experience

To qualify for this University Health Network career opportunity in Toronto, candidates must meet specific educational, professional, and technical standards:

• Undergraduate or Graduate degree in a related health profession.
• Current membership in good standing with applicable or relevant regulatory health professional body in Ontario is required.
• Five years of clinical experience required, with experience in a community health setting preferred.
• Five years of recent, related acute care setting experience required.
• Demonstrated experience and competence in areas of patient need relevant to orthopedic surgery and cardiology required.
• 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 or influence behavior of others are required.
• Demonstrated ability to work both independently and collaboratively with an interdisciplinary team and support networks 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 driver’s license, adequate insurance with a minimum $1 million liability limit, and use of a reliable vehicle that qualifies physical damage coverage is required.