Transitional Lead

As a Transitional Lead (TL) in CBI Home Health' specialized, integrated care programs, you will play a pivotal role in shaping seamless, patient-centered transitions from hospital to home, ensuring every individual receives the right care at the right time. Partnering closely with hospital teams, community partners, and families, you'll create comprehensive care plans that support safe discharges and empower patients to thrive sustainably at home.

As the primary point of contact, you'll be a trusted guide for patients and their families-providing consistent check-ins, home visits, and ongoing support to ensure their goals are met. Collaborating with an interdisciplinary care team, you'll identify solutions for emerging challenges and proactively monitor patient progress. In this dynamic role, you'll also track and analyze service utilization, documentation, and key performance metrics (KPIs) to continuously improve care delivery. Your keen insights and innovative thinking will drive quality improvements and uncover new growth opportunities to keep our programs on the leading edge of care.

Here's a look at our total rewards:

• Competitive compensation package and benefits
• Paid orientation and training time
• Group benefit plan, including Employee Assistance Program
• Home Health Ontario Retirement Savings Program*
• Mobile technology and training provided
• Supportive supervisory and management team who listen and support you
• Safety-first work culture a top priority
• Opportunities to grow your career within CBI Health's national network

About this Opportunity

Program Ambassador and Partner Liaison 30%

• Primary contact for interdisciplinary team and operational partners (hospital, community support services, etc. ) involved in transition planning of patients.
• Participate and contribute to daily hospital huddles related to new referrals, planned discharges, and problem-solving.
• Participate in patient and program-related meetings as required, including leading interdisciplinary team-based huddles.
• Establish and foster positive partnerships with key internal and external stakeholders; this can include the preparation and presentation of key data, outcomes and action planning.
• Ensure that CBI Home Health care team members have the appropriate and timely information for effective care delivery and transitions.

Patient Coordination & Navigation 40%

• Create a transitional care plan to support an effective transition out of the hospital, identifying and coordinating services and supports required for a sustainable transition home.
• Work closely with CBI Home Health team to coordinate services and supports to meet patient needs upon admission and ongoing; this includes adjusting care plans and team-based interventions.
• Lead/participate in patient care conferences to review goal progression, service gaps, and barriers to discharge.
• Leverage key software, dashboards, and digital enablers to optimize team members and the patient, family, and provider experience, inform care planning activities, and achieve intended program outcomes.
• Lead/participate in the development of proactive and suitable community transition, restorative health, and discharge care plans involving the patient and circle of care.
• Regularly communicate with and involve primary care providers (PCP) in the patient's care plan, goals and progress. This includes working with the interdisciplinary team to support PCP visits within 7 days of service initiation.
• Effectively communicate with patients and families throughout transitions: discharge from hospital and transition to community.
• Ensure effective collaboration and knowledge transfer with CBI Home Health resources to coordinate services and ensure a safe and smooth transition.
• Engage the CBI Home Health interdisciplinary team to problem solve and identify innovative solutions to situations.

Program Integrity & Quality 30%

• Monitor and ensure appropriate documentation, clinical outcome measures, and metrics are completed for each patient as per CBI Home Health program standard.
• Monitor data and documentation integrity and identify any gaps or issues accordingly.
• Contribute to the collection and analysis of data and metrics for reporting purposes.
• Monitor program service utilization and proactively identify any concerns or risks.
• Identify any trends or opportunities for program improvement and escalate them accordingly with suggested solutions.
• Participate and lead in program evaluation activities as required.
• Coordinate and apply patient, and caregiver experience surveys for timely experience information gathering & analysis as per program standards.
• Coordinate and apply staff/provider experience surveys as per program standards.

What you will need to be successful;

• Regulated Health Professional registered and in good standing with the respective College.
• Strong clinical skill set and demonstrated commitment to best-practice care.
• Postgraduate education such as a Master's level degree or advanced university/executive training considered an asset.
• 5+ years' experience in a general management role in a service-focused organization, home and community care experience preferred.
• Clear vulnerable sector screening.
• Ability to lead teams and individuals to achieve results.
• Demonstrated success with program evaluation and improvement.
• Experience with clinical program monitoring.
• Possess excellent communication and organizational skills with the ability to work as part of a team in a fast-paced environment.
• Have strong knowledge of quality improvement strategies, and health care system, and experience in home and community care.
• Be comfortable interacting with internal and external stakeholders within partner organizations.
• Combine a demonstrated patient and family-centered focus with a commitment to providing quality care.
• Demonstrated competency with MS Office suite of tools.
• A valid driver's license and reliable vehicle are required and the ability/willingness to travel within the Peterborough Region.

Join us at CBI Home Health - Because Your Care Matters

CBI Home Health is committed to providing a diverse, equitable, and inclusive workplace where everyone feels safe and accepted as their authentic selves. We actively seek qualified candidates who share our commitment to equity and inclusion and contribute to the diversification of ideas and perspectives that help us innovate and provide the best possible care to our clients.

We are committed to fostering a positive experience for all Indigenous applicants whether you're First Nations (status or non-status), Inuit or Metis, and welcome applications from all individuals regardless of race, colour, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, veteran status, or any other characteristics that make each of us different.

In accordance with the Ontario Human Righ.