Integrated Care Lead Connected Care

Union: NonUnion 
Department: UHN Connected Care
Site: Hospital and Community Setting
Reports to: Manager
Work Model: OnSite
Hours: 37.5 hours per week
Shifts: Varies per week; flexibility for evenings and/or weekend shifts
Salary: $45.48 $56.85 per hour (To commensurate with experience and consistent with UHN compensation policy)
Status: Permanent FullTime(contingent on continued funding)
Closing Date:January 18 2025

POSITION SUMMARY:

The Integrated Care Lead is a critical member of the Integrated Care Program and is the primary contact for patients essential care partners and the clinical team representing acute care as well as home and community care services. Dual Reporting to the Manager of the Connected Care Hub. The IC Lead provides leadership for the patient experience by working closely to create one care team to deliver exceptional care and improves the experience and satisfaction of the entire care team. As a leader in a multidisciplinary care team this role focuses on providing comprehensive care to support patients overall health and wellbeing including patientcentered navigation intensive case management and coordination of services to patients as they access care within University Health Network and with partner organizations. The IC Lead will be supporting the integrated clinical pathways that focus on CHF Lower Limb Preservation and at a later date may include COPD and Stroke.

Duties:

• Acting as the key lead liaising between patients the UHN clinical team community providers primary care providers and other providers to ensure all components of a patients care are provided.
• Developing supporting and overseeing a patients 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 home visits when required to facilitate patient care and/or inhome training and support for homecare team.
• Working collaboratively with an interprofessional 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 selfmanagement 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 UHNs Safety and Quality policies and procedures.
• Provide crosscoverage of other IC Programs and pathways.

Qualifications :

• Undergraduate/Graduate degree in a related health profession.
• Current membership in good standing with applicable/relevant regulatory health professional body in Ontario is required.
• Five (5) years of clinical experience required experience in a community health setting preferred
• Five (5) years of recent related acute and community care setting experience required.
• Demonstrated experience and competence in areas of patient need relevant to the CHF and Diabetes chronic disease management and a willingness to learn or existing knowledge regarding other patient populations an asset community and hospital that focused on the management of chronic disease management such as CHF diabetes and vascular surgery.
• Demonstrated experience working with the Indigenous population is an asset
• Demonstrated experience and competence in case management is preferred.
• Demonstrated recent comprehensive knowledge of community resources and health care delivery systems in acute and community settings is preferred.
• Demonstrated willingness and ability to use new assessment tools and systems as required by the Ministry or in keeping with legislated requirements.
• Demonstrated ability to quickly respond to patients and situations with resourcefulness flexibility and adaptability is required.
• Excellent interpersonal communication organizational and decisionmaking skills required.
• Demonstrated leadership skills including problem solving critical thinking conflict resolution and the ability to effectively persuade / influence behaviour of others to align with patient care objectives and desired outcomes are required.
• Demonstrated ability to work both independently and collaboratively with an interdisciplinary team family members support networks and a variety of formal and informal service providers including home and community care 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 drivers license adequate insurance (personal automobile policy with a minimum $1 million liability limit) and use of a reliable vehicle that qualifies for physical damage coverage is required.
• Undergraduate/Graduate degree in a related health profession.
• Current membership in good standing with applicable/relevant regulatory health professional body in Ontario is required.
• Five (5) years of clinical experience required experience in a community health setting preferred
• Five (5) years of recent related acute and community care setting experience required.
• Demonstrated experience and competence in areas of patient need relevant to the CHF and Diabetes chronic disease management and a willingness to learn or existing knowledge regarding other patient populations an asset community and hospital that focused on the management of chronic disease management such as CHF diabetes and vascular surgery.
• Demonstrated experience working with the Indigenous population is an asset
• Demonstrated experience and competence in case management is preferred.
• Demonstrated recent comprehensive knowledge of community resources and health care delivery systems in acute and community settings is preferred.
• Demonstrated willingness and ability to use new assessment tools and systems as required by the Ministry or in keeping with legislated requirements.
• Demonstrated ability to quickly respond to patients and situations with resourcefulness flexibility and adaptability is required.
• Excellent interpersonal communication organizational and decisionmaking skills required.
• Demonstrated leadership skills including problem solving critical thinking conflict resolution and the ability to effectively persuade / influence behaviour of others to align with patient care objectives and desired outcomes are required.
• Demonstrated ability to work both independently and collaboratively with an interdisciplinary team family members support networks and a variety of formal and informal service providers including home and community care 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 drivers license adequate insurance (personal automobile policy with a minimum $1 million liability limit) and use of a reliable vehicle that qualifies for physical damage coverage is required.

Additional Information :

In addition to working alongside some of the most talented and inspiring healthcare professionals in the world UHN offers a wide range of benefits programs and perks. It is the comprehensiveness of these offerings that makes it a differentiating factor allowing you to find value where it matters most to you now and throughout your career at UHN. 

• Competitive offer packages 
• Government organization and a member of the Healthcare of Ontario Pension Plan (HOOPP ) 
• Close access to Transit and UHN shuttle service 
• A flexible work environment  
• Opportunities for development and promotions within a large organization 
• Additional perks (multiple corporate discounts including: travel restaurants parking phone plans auto insurance discounts onsite gyms etc.) 

Current UHN employees must have successfully completed their probationary period have a good employee record along with satisfactory attendance in accordance with UHNs attendance management program to be eligible for consideration.  

All applications must be submitted before the posting close date.

UHN uses email to communicate with selected candidates.  Please ensure you check your email regularly.

Please be advised that a Criminal Record Check may be required of the successful candidate. Should it be determined that any information provided by a candidate be misleading inaccurate or incorrect UHN reserves the right to discontinue with the consideration of their application.

UHN is an equal opportunity employer committed to an inclusive recruitment process and workplace. Requests for accommodation can be made at any stage of the recruitment process. Applicants need to make their requirements known.

We thank all applicants for their interest however only those selected for further consideration will be contacted.

Remote Work :

No

Employment Type :

Fulltime