Supervisor, Hospital to Home Program

Job Description

The Supervisor provides clinical and coordination leadership to the integrated team of the Hospital to Home Program. With a focus on the social determinants of health, each member of the team works within the program guidelines to support patients recently discharged from Sinai Health. The program is intended to provide wrap-around services to support the transition from hospital to home and optimize functional recovery through self-efficacy and chronic disease management. To touch as many lives as possible and positively impact patient and family outcomes while on the program, the Supervisor will monitor evidence informed practice, continually assess progress and services; ensure financially sustainable home care and communicate with point of care and program partners to ensure the patient and program goals are met. In addition, the Supervisor engages with patients and caregivers to assess their needs at admission, throughout their care, and support their transition off the program, while ensuring a positive patient and provider experience. The Supervisor will work closely with the Coordinator to ensure the seamless flow of patients through this program, ensuring that KPIs and outcomes are tracked and monitored as per our funder requirements.

We are looking for: A full-time Supervisor, Hospital to Home (12 Month Contract)

Salary: Commensurate with experience

Hours of Work: 34 hours/week. Mon - Thurs 8:30am - 4:30pm, Fri - 8:30am - 3:30pm.

This is a hybrid work from home role which requires 3 days in office per week and the ability to travel in the community as needed. Required to contribute to a rotating on-call schedule.

Reports to: Manager, Client Services

Responsibilities

General Accountabilities

• Ensure a patient-centered and trauma informed framework to promote autonomy and resilience while respecting cultural diversity in all patient and family interactions.
• Use motivational interviewing and active listening with patients, families, and partners to address dissatisfaction, frustration, and escalation.
• Promote program goals, values and outcomes consistent with the program model to achieve optimal progress, prevent readmission to hospital and sustainable health and social care.
• Demonstrate comprehensive care planning and coordination as part of an integrated team.
• Monitor submission of Professional Service Reports to meet COC or other funder KPI's or requirements and outcome measures by profession.
• Facilitate seamless, supportive, and non-judgmental transitions for patients moving from hospital to home care, ensuring clear communication and empathy throughout the process.
• Monitor goal completion by the interprofessional team.
• Collaborate with the hospital teams to address post-discharge barriers and guide patient care transition plans.
• Ensure appropriate medical supplies and equipment are ordered for patient care, aligning with treatment needs and program requirements.
• Develop accurate and time-sensitive patient services plans for clarity and effective communication with point of care and partner organizations.
• Facilitate successful transition off the program, providing a warm hand off.
• Work collaboratively with program partners to ensure program goals, outcomes, and KPIs are met.
• Monitor and reports on Missed Care, NSNS and Service Refusals.
• Attend daily huddles and weekly clinical huddle with Sinai Health and ensure reporting requirements are met.
• Actively contribute to the program design and offer feedback to enhance care transitions and overall program success.
• Perform root cause analysis for adverse events and implement preventative measures.

Patient Admission

• Review referrals for urgency, risk, appropriate service ordering, and need for medical equipment and supplies.
• Collaborate with the hospital to gather critical patient safety information including medical orders.
• Ensure the InterRAI-CA is completed on admission and review for service planning.
• Contact patients/families to introduce the program, address questions, engage them in co-design of their care plan, and update for discharge planning.
• Complete the Patient Service Plan in a timely manner to support the Coordinator's role in service ordering and distribute to point of care team members/partners.

Ongoing Patient Oversight

• Maintain communication with patients/families, and care team regarding critical information, progress and outcomes.
• Address patient/family compliments, concerns, complaints and support resolution.
• Monitor services and ensure implementation of the Patient Service Plan.
• Escalate reportable issues to hospital team lead and track patient data, outcomes, and KPIs.
• Ensure ongoing communication with their primary care provider or most responsible provider.

Professional Service Reports

• Provide guidance and feedback to ensure Professional Service Reports are submitted.
• Review and approve Professional Service Reports and ensure goals and service adjustments align with patient needs and pathway limitations and communicate adjustments to patients and families.

Huddles

• Lead daily huddles with the team and weekly huddles with Sinai Health leadership and service partners.
• Identify patients for periodic reviews and facilitate discussions on service plan adjustments.

Transitions/Discharge Planning

• Organize case conferences for complex patients one month prior to discharge.
• Submits referrals to Ontario Health at Home.
• Prepare and share discharge plans, including ongoing referral needs.
• Ensure all necessary documentation is completed and stored in EasyCare or other locations to maintain secure PHI.

Leadership

• Provide guidance to staff and service providers regarding questions and concerns about the program goals and operations.
• Manage crises and support integrated team collaboration.
• Assist Coordinator with any clinical issues involving service ordering.
• Reach out for leadership support to manage acute changes in workload.

On-Call Rotation

• Participate in the on-call rotation, and support with vacation coverage.
• Complete home visits to provide treatment which can include wound care, Comprehensive assessment, Catheter insertion, Medication Administration Oral/Iv, or based on patient needs.
• Conduct delegation visits for PSWs or shadow visits that cannot be completed during business hours to oversee PSWs working evening shifts.
• Provide support to patients and their families as needed after hours.
• Prioritize patients admitted to the program, who are obligated to receive nursing visits during the first seven days of admission.
• Any home visits required over the weekend.

Risk, Health and Safety Management

• Identifying and reporting health and safety incidents and concerns in a timely manner to the appropriate supervisors and/or funders, documenting incidents in EasyCare and escalating appropriately to the designated supervisors as outlined in the Client Safety Reporting policy (C
• Participating in health and safety processes and procedures.
• Participating in maintaining a safe workplace environment by cultivating a positive safety culture and encouraging best practices to promote both staff and client safety and well-being
• Participating in all health and safety training initiatives on a regular basis.
• Taking proactive action against client incidents within your scope of practice.
• Developing a plan to identify, manage and/or minimize client safety risks or situations in adherence with risk management operations policies.
• Assessing the severity of an adverse client safety/risk event and determining the best follow-up and developing an action plan following the event. Collaborating with funder (ex. HCCSS) and following any additional processes as required.
• Calling emergency services (911) when the client is at an immediate risk of harming themselves or others, or if there is a serious injury and/or imminent harm.
• Evaluating any potential hazards and identifying clients at risk for adverse health and safety events, taking preventative measures when necessary to minimize reoccurrence.
• Reporting all safety events impacting clients, caregivers and families in a timely and honest disclosure.

Qualifications

• Registered Nurse or Registered Practical Nurse with current CNO registration in good standing.
• Excellent knowledge of the social determinants of health, their impact on clinical outcomes and awareness of the key contributions of community support service organizations.
• Experience working in home, hospital, or community-based care with elderly/frail people.
• Knowledge of population health and vulnerable populations (elder adults, Indigenous people, people living with mental health and addictions, LGBTQ+).
• Commitment to evidence informed clinical practice and outcome measures, professional practice models and professional college practice requirements in Ontario.
• Expertise in evaluating safety and risk for patients with weight bearing and transfer issues requiring personal support.
• Knowledge of interprofessional team roles and scopes of practice and experience with home care service ordering.
• Competency in leading unregulated care providers and knowledge of the requirements and restrictions in the role of rehabilitation assistants.
• Experience in patient assessments requiring personal support to ensure quality and safe patient outcomes.
• Ability to work in a fast-paced setting with excellent problem-solving and assessment skills.
• Excellent interpersonal, problem-solving, and communication skills.
• Highly organized, able to work independently.
• Competency in data analytics and use of Microsoft Office.
• Must have a valid Driver's License and access to a vehicle.
• French language proficiency is an asset.

Additional information

Circle of Care is committed to fostering an inclusive, accessible environment, where all employees, volunteers and clients feel valued, respected and supported. We are dedicated to building a workforce that reflects the diversity of the communities in which we live and serve, and creating an environment where every employee has the opportunity to reach their potential. Circle of Care seeks applicants who embrace our values of equity, anti-racism, and inclusion. As such, we encourage applications from candidates who have been historically disadvantaged and marginalized, including but not limited to those who identify as First Nations, Métis and/or Inuit/Inuk, Black, members of racialized communities, persons with disabilities, women and/or 2SLGBTQ+.

We are committed to an environment that is barrier free. If you require accommodation, please inform us in advance.

We thank you for your interest in Circle of Care. We welcome you to apply for this role, even if you do not meet every requirement listed. Only applicants who are selected for an interview will be contacted.

Powered by people. Sparked by passion. Circle of Care is made up of staff, students, and volunteers who bring energy and purpose, every day.