Integrated Care Lead

UHN is Canada's #1 hospital and the world's #1 publicly funded hospital. With 10 sites and more than 44,000 TeamUHN members, UHN consists of Toronto General Hospital, Toronto Western Hospital, Princess Margaret Cancer Centre, Toronto Rehabilitation Institute, The Michener Institute of Education and West Park Healthcare Centre. As Canada's top research hospital, the scope of biomedical research and complexity of cases at UHN have made it a national and international source for discovery, education and patient care. UHN has the largest hospital-based research program in Canada, with major research in neurosciences, cardiology, transplantation, oncology, surgical innovation, infectious diseases, genomic medicine and rehabilitation medicine. UHN is a research hospital affiliated with the University of Toronto.

UHN's vision is to build A Healthier World and it's only because of the talented and dedicated people who work here that we are continually bringing that vision closer to reality.

www.uhn.ca

Union: Non-Union
Department: Peter Munk Cardiac Center
Site: Toronto General Hospital or Toronto Western Hospital
Reports to: Manager
Work Model: On-Site
Wage Range: $45.48 - $59.12 per hour (to commensurate with experience and consistent with UHN compensation policy)
Hours: 37.5 Hours per Week
Shifts: Various (mostly day shifts, must be available for on-call, days/afternoon/evenings rotation and/or weekends)
Status: Temporary Full-time, contingent on continued funding (End Date ~ August 8, 2025)
Closing Date: February 24, 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 Director UHN@Home and the relevant Clinical Leadership, 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 a patients overall health and well-being including patient-centered navigation, intensive case management and coordination of services to patients as they access care within University Health Network and with partner organizations.

Duties

• Acting as the key lead liaising between patients, the UHN cardiovascular surgery team, community providers, primary care providers, and other providers, to ensure all components of a patient's care are provided.
• Developing, supporting and overseeing a patient's 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 in-person and/or remote home visits when required to facilitate patient care and/or in-home training and support for homecare team.
• Working collaboratively with an inter-professional 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 self-management 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 UHN's Safety and Quality policies and procedures.
• Provide cross-coverage of other IC Programs and pathways.

• 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 care setting experience required.
• Demonstrated experience and competence in areas of patient need relevant to surgery including Transplant, and willingness to learn or existing knowledge regarding other surgical pathways 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 decision-making 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 driver's 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.

Why join UHN?

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 https://hoopp.com/)
• 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, on-site gyms, etc.)

Current UHN employees must have successfully completed their probationary period, have a good employee record along with satisfactory attendance in accordance with UHN's 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.