Integrated Care Lead
- Orthopedic Surgery and Cardiology
- Full-time 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. Union: Non-Union Number of Vacancies: 1 New or Replacement: Replacement Site:Toronto Western Hospital Department: UHN at Home; Initial Assignment –Orthopedic Surgery and Cardiology Reports to: Manager, UHN at Home. Work Model: On-Site Hours: 37.5 hours per week Shifts: Mostly day shifts, must be available for on-call, days/afternoon/evenings rotation and/or weekend

Salary:
$46.85
- $58.56 per hour (To commensurate with experience and consistent with UHN compensation policy) Status:Temporary Full-Time (18 months) Closing Date: October 28, 2026 Position Summary The Integrated Care Lead is a critical member of the UHN at Home 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. Reporting to the UHN at Home Manager, 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 patient’s 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 surgical 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.
- 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 orthopedic surgery and cardiology required
- 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 current assessment tools an

📌 Integrated Care Lead (Toronto)
🏢 University Health Network
📍 Toronto