Transitional Care Coordinator - Corporate Discharge Planners

The Transitional Care Coordinator practices in accordance with standards of professional practice and the Osler corporate mission, vision and values that support a model of inter-professional collaboration as a vehicle to facilitate practice culture and support a patient-focused model of care. The Transitional Care Coordinator supports the delivery of a superior care experience to all patients and their families by practicing as an equal member of a core team of skilled professionals working to full scope of practice to ensure that each patient has a comprehensive patient assessment, care plan and timely and effective discharge plan.

Accountabilities:

In collaboration with the inter-professional team, the Transitional Care Coordinator coordinates decision-making for patient transfer and discharge beginning at the point of admission and throughout the hospitalization:

• Screens all admissions for early identification of high-risk discharges (within 24 hours of admission) and documents accordingly
• Conducts a risk assessment using standardized tools and communicates results of the risk assessment to the inter-professional team
• Meets with the patient and family to determine pre-...