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Coordinate discharge and transition, and ensure patients are safely discharged or transferred to their appropriate destination. Establish and maintain a systematic review and assessment of bed availability. Ensure appropriate designation and management of Alternate Level of Care (ALC) patients.

REPORTING:

Under the general direction of the Manager, Utilization, Care Transitions and ALC Leading Practices.

DUTIES:

- Determine the expected date of discharge; ensure all necessary assessments, investigations and other procedures are completed; ensure that discharge proceeds on the scheduled date.
- Participate in implementing and coordinating a patient-centered care plan with patients, family members, significant others, and the multi-disciplinary team for the purpose of facilitating the patient’s movement through the continuum of care.
- Provide a link between the hospital community agencies and ALC facilities.
- Review all incoming applications, liaise and establish contact with members of the multi-disciplinary team and appropriate community agencies.
- Educate hospital staff to the various aspects of discharge planning and available resources.
- Interact and engage patients and Substitue Decision Maker in initial and continued Home First Philosophy conversation.
- Manage Point of Care System (PCS) documentation in Expanse for all ALC patients (e.g. new orders, changes and discontinuations).
- Determine eligibility of all ALC designations in accordance with provincial guidelines, organizational policy and clinical criteria.
- Promote early identification of barriers to achieving Estimated Date of Discharge and engage in solutions to those barrier.




- Manage escalation process for at-risk and Long-Term Care (LTC) patients, resolving issues and barriers before escalation to management.
- Act as the primary point of contact for escalation and knowledge of ALC patients for inpatient teams and external stakeholders, providing issue resolution and coordination prioir to escalation to management.
- Act as a clinical resource for the acute inter-professional teams by providing information based on clinical knowledge and theory/practice related to clients with complex health care needs.
- Attend and contribute to daily meetings (bed rounds, inpatient unit bullet rounds, etc.) and be aware of daily bed pressures.
- Lead ALC rounds for the organization.
- Develop strong relationships with physicians and interdisciplinary team members across the organization to develop clear plans and pathways to ensure strong support for individuals being served by the organization.
- Document action taken and progress on Patient Action Manager or chart as required.
- Engage third party participants in improvement intiatives as required.
- Coordinate with related departments and functions to ensure appropriate information flow and understanding of overall process improvement direction.




- Work with multi-organizational teams to identify and prioritize opportunities to further design, develop and/or improve future state processes and standards of work related to discharge planning and ALC avoidance.
- Determine and align improvement projects with HSN’s Strategic Plan; monitor and adjust to achieve goal outcomes.
- Contribute to learner development by providing academic support, mentorship, preceptorship and supervision as required.
- Participate in education and training specific to current, relevant federal and provincial health and safety legislation, standards and guidelines.
- Educate and promote health, safety and wellness in the work place.
- Represent the department or program on various committees and in meetings as required.
- Perform other duties as required.

QUALIFICATIONS

EDUCATION AND TRAINING:

- Minimum of a four (4) year Bachelor’s Degree from an accredited university.
- Current Certificate of Registration in valuable standing with a regulatory college is preferred.
- Additional specialized training in geriatrics is preferred.
- Ministry of Labour “Worker Health and Safety Awareness in 4 Steps” training certificate is required.

EXPERIENCE:

- Minimum of five (5) years’ experience working in a health care environment.
- Experience in using utilization management principles and length of stay management strategies is preferred.
- Experience in utilization of assessment tools (e.g. Appropriate Use of Antipsychotics (AUA), Barthel Index, Blaylock, etc.) is preferred.
- Experience working with the elderly and their care givers/informal supporters is preferred.
- Experience working with multidisciplinary teams, physicians, patients

📌 Home First Liaison (Greater Sudbury)
🏢 Hsnsudbury
📍 Greater Sudbury