Home First Liaison

KEY FUNCTION:

Coordinate discharge and transition, and ensure patients are safely discharged or transferred to their appropriate destination. Establish and maintain a systematic review and assessment of bed availability. Ensure appropriate designation and management of Alternate Level of Care (ALC) patients.

REPORTING:

Under the general direction of the Manager, Utilization, Care Transitions and ALC Leading Practices.

DUTIES:

1. Determine the expected date of discharge; ensure all necessary assessments, investigations and other procedures are completed; ensure that discharge proceeds on the scheduled date.
2. Participate in implementing and coordinating a patient-centered care plan with patients, family members, significant others, and the multi-disciplinary team for the purpose of facilitating the patient’s movement through the continuum of care.
3. Provide a link between the hospital community agencies and ALC facilities.
4. Review all incoming applications, liaise and establish contact with members of the multi-disciplinary team and appropriate community agencies.
5. Educate hospital staff to the various aspects of discharge planning and available resources.
6. Interact and engage patients and Substitue Decision Maker in initial and continued Home First Philosophy conversation.
7. Manage Point of Care System (PCS) documentation in Expanse for all ALC patients (e.g. new orders, changes and discontinuations).
8. Determine eligibility of all ALC designations in accordance with provincial guidelines, organizational policy and clinical criteria.
9. Promote early identification of barriers to achieving Estimated Date of Discharge and engage in solutions to those barrier.
10. Manage escalation process for at-risk and Long-Term Care (LTC) patients, resolving issues and barriers before escalation to management.
11. Act as the primary point of contact for escalation and knowledge of ALC patients for inpatient teams and external stakeholders, providing issue resolution and coordination prioir to escalation to management.
12. Act as a clinical resource for the acute inter-professional teams by providing information based on clinical knowledge and theory/practice related to clients with complex health care needs.
13. Attend and contribute to daily meetings (bed rounds, inpatient unit bullet rounds, etc.) and be aware of daily bed pressures.
14. Lead ALC rounds for the organization.
15. Develop strong relationships with physicians and interdisciplinary team members across the organization to develop clear plans and pathways to ensure strong support for individuals being served by the organization.
16. Document action taken and progress on Patient Action Manager or chart as required.
17. Engage third party participants in improvement intiatives as required.
18. Coordinate with related departments and functions to ensure appropriate information flow and understanding of overall process improvement direction.
19. Work with multi-organizational teams to identify and prioritize opportunities to further design, develop and/or improve future state processes and standards of work related to discharge planning and ALC avoidance.
20. Determine and align improvement projects with HSN’s Strategic Plan; monitor and adjust to achieve goal outcomes.
21. Contribute to learner development by providing academic support, mentorship, preceptorship and supervision as required.
22. Participate in education and training specific to current, relevant federal and provincial health and safety legislation, standards and guidelines.
23. Educate and promote health, safety and wellness in the work place.
24. Represent the department or program on various committees and in meetings as required.
25. Perform other duties as required.

QUALIFICATIONS

EDUCATION AND TRAINING:

1. Minimum of a four (4) year Bachelor’s Degree from an accredited university.
2. Current Certificate of Registration in good standing with a regulatory college is preferred.
3. Additional specialized training in geriatrics 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 a health care environment.
2. Experience in using utilization management principles and length of stay management strategies is preferred.
3. Experience in utilization of assessment tools (e.g. Appropriate Use of Antipsychotics (AUA), Barthel Index, Blaylock, etc.) is preferred.
4. Experience working with the elderly and their care givers/informal supporters is preferred.
5. Experience working with multidisciplinary teams, physicians, patients and families to improve outcomes is preferred.
6. Experience in leadership and project management is preferred.

KNOWLEDGE/SKILLS/ABILITIES:

1. Demonstrated ability to de-escalate crisis situations.
2. Demonstrated knowledge of risk assessement tools.
3. Demonstrated knowledge of health research and/or best practice guidelines in discharge planning and ALC avoidance.
4. Demonstrated knowledge of key system constraints based on analysis of date and trends.
5. Demonstrated excellent judgment and proven analytical skills.
6. Demonstrated training, experience or utilization of quality improvement methodology for process improvement.
7. Demonstrated ability to independently identify issues, plan improvements, measure success and continue improvement.
8. Demonstrated excellent computer skills with proficiency in Microsoft Office software (e.g. Word, Excel, Power Point and Outlook) and patient information systems.
9. Demonstrated superior, interpersonal and communication skills, both written and verbal.
10. Demonstrated effective time management and organizational skills with the ability to organize and prioritize as required.
11. Demonstrated ability to manage routine correspondence, multiple tasks/projects, diversified workload and rapidly changing priorities and challenging deadlines.
12. Demonstrated discretion and maturity when handling confidential information.
13. Demonstrated commitment to the safety of co-workers and patients.

PERSONAL SUITABILITY:

1. Successful Vulnerable Sector Check is required.
2. Ability to use tact and discretion in dealing with health care providers and patients.
3. Proven ability to work independently and in a team environment.
4. Demonstrated ability to work effectively as a member of an interdisciplinary team.
5. Demonstrated ability to perform with minimal supervision; to prioritize duties.
6. Excellent time management skills with ability to multi-task.
7. Demonstrated commitment to ongoing professional development.
8. Demonstrated professionalism in dealing with confidential and sensitive issues.
9. Demonstrated positive work record and excellent attendance record.
10. Ability to meet the physical and sensory demands of the job.
11. Ability to travel between local sites.
12. Demonstrated ability to work flexible hours as required.

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. This posting is for an existing vacancy.

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.