HNHB Local Health Integration Network

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Full Time Manager, Integrated Transitions in Care (Niagara Health & HNHB LHIN - 3 positions available)

Full Time Manager, Integrated Transitions in Care (Niagara Health & HNHB LHIN - 3 positions available)

Competition Number 
NIAGARA - Office
Position Group 
Non Union
Closing Date 
Length of Term 
n/a - PERM
Hours of Work 
Monday - Friday, 8:30am - 4:30pm

More information about this job

Position Summary

Niagara Health (NH) and the Hamilton Niagara Haldimand Brant (HNHB) Local Health Integration Network (LHIN) are committed to ensuring patient centered transitions comprising of a coordinated, interdisciplinary approach from the time of admission through to discharge to the community. NH and the HNHB LHIN have a joint responsibility to the community to optimize the appropriate use of hospital resources ensuring acute care and specialized rehabilitation beds/services are available for patients requiring such levels of care. Establishing a NH & HNHB LHIN interdisciplinary team to carry out early discharge planning processes optimizes patient centered care and facilitates a timely and seamless transition from hospital to the community.


Congruent with the mission, vision and values of both Niagara Health & HNHB LHIN Integrated Manager of Transitions in Care is committed to providing Extraordinary care - Every person, Every Time and will embrace the shared values of respect, integrity, caring innovation, accountability, transparency and optimism.


With joint accountability to the NH Site Executive Lead and CNO and the HNHB LHIN Director of Home and Community Care , the Integrated Manager of Transitions in Care (3 positions) will provide operational leadership in the effective transition/discharge of patients from the NH hospital sites to the community.


The NH /HNHB LHIN Integrated Manager of Transitions in Care will directly lead identified staff whose function focuses on the scope of discharge planning and transitions in care from hospital. She/he will be the link connecting the two organizations to embed the philosophy of Home First in all relevant processes supporting seamless and timely transitions between hospital and community.

Core Duties - Responsibilities

Day to Day Operational Management

  • Plans, manages, and evaluates the delivery of discharge planning processes and transitions in care from NH.
  • Accountable for effective team functioning in service and performance standards.
  • Monitors and adjusts caseloads, workload and assignments within the hospital portfolio to maximize efficiency.
  • Collaboratively manages complex and difficult patient issues and complaints with timely investigation and follow-up.
  • May attend/support staff in Consent & Capacity Review Board hearings, service appeals and legal consultations.
  • Acts as a key resource to NH and HNHB LHIN staff, other managers, service providers and external stakeholders.
  • Ensures that standards are maintained with respect to the assessment of patient needs, planning and coordination, to support patients and their caregivers
  • Operationally, interprets NH and HNHB LHIN organizational directions, goals and performance standards at the team level.
  • Reviews the current status of ALC patients as required with the clinical teams and assists with problem-solving to support timely and supportive discharge.
  • Monitors and manages resources as required according to established guidelines and NH/HNHB LHIN priorities.
  • Assesses and identifies critical service delivery issues and risks to NH and recommends/implements service improvements as required.
  • Evaluates and identifies the hospital and community impact of proposed changes within assigned portfolio. .
  • Provides leadership in the development of communication materials to patients and families with respect to admission, hospital stay and discharge.
  • Ensures patient services are provided in accordance with NH and HNHB LHIN policies, relevant LTC Legislation, Public Hospital Act, other standards and guidelines.
  • Creates mechanisms for improved communication, decision-making, and alignment between NH and HNHB LHIN team members and the broader health system.

Coach, Mentor and Act as Resource to Staff

  • Facilitates an environment promoting team spirit, creativity and innovation in the delivery of care and services.
  • Champions the Home First Philosophy as a fundamental patient right and priority in discharge planning.
  • Works closely with leadership teams, stakeholders, physicians, and interdisciplinary teams to ensure the Home First Philosophy is embedded in all relevant processes.

Monitors Quality and Utilization

  • Works collaboratively with NH leadership teams to strategize and implement changes to practice that achieve ALC target benchmarks.
  • Monitors NH ALC performance metrics and reports variances.
  • Participates as required with NH and HNHB LHIN leadership with respect to utilization/quality indicators.
  • Participates in the development of NH processes to monitor quality, identify and manage risks to patient care with respect to discharge planning activities and transitions in care.

Lead Process Improvements and Act as Change Agent

  • Leads and/or participates on internal NH/HNHB LHIN committees/projects to develop and implement strategies aimed at improving patient care.
  • Identifies opportunities and implements best practices to ensure quality patient care, consistent with the NH and HNHB LHIN organizational and divisional directions.
  • Supports and leads change through innovation.
  • Follows through on identified opportunities for continuous quality improvement. 

Financial Accountability

  • Contributes to the fiscal success of programs/portfolios.
  • Works collaboratively with all healthcare team members to optimize the use of resources.
  • Identifies and implements opportunities to optimize efficiencies.
  • Participates in financial responsibility through the measurement and evaluation of resources. 

Strategy and Building Systems in Partnership with Others

  • In partnership with senior leaders, prepares and supports individuals and teams in making system level changes related to discharge planning and transitions in care.
  • Establishes partnerships and linkages with other providers with the aim of improving the utilization of health care resources along the care continuum.
  • Contributes to the development of NH and the HNHB LHIN’s strategic and operational planning.
  • Establishes and maintains effective working relationships across NH sites, other hospitals, primary care, community and stakeholders.
  • Manages the implementation and evaluation of new NH and HNHB LHIN service initiatives using principles of change management.
  • Participates and/or facilitates working groups and focus groups to support system efficiency, integrated service delivery and best practice.
  • Represents NH and HNHB LHIN on local and provincial initiatives where appropriate.
  • Participates in community events, including formal presentations, to promote NH & HNHB LHIN objectives, activities, programs and services.


  • Regulated Health Care Professional in good standing with respective health professional regulatory body in Ontario is preferred.
  • University degree in a health-related field, Master's level preparation an asset
  • Minimum 5 years management experience working within a unionized healthcare environment
  • Demonstrated recent knowledge of NH/Acute Care and HNHB LHIN Home & Community Care priorities, policies, practices and service standards
  • Recent experience leading quality improvement initiatives
  • Recent experience leading interprofessional team(s) through change at a system level

Skills & Abilities

  • Expert knowledge and understanding of legislation governing health care delivery
  • Knowledge of direct care/case management models used in community health care
  • Demonstrated knowledge of local health and community services
  • Working knowledge of financial and statistical reporting
  • Effective organizational skills allowing to prioritize and respond to multiple competing demands within defined time lines
  • Proficient computer and business skills
  • Excellent communication skills with a variety of audiences internally and externally
  • Expert collaboration and negotiations skills
  • Excellent leadership skills to promote team building and positive organizational culture
  • Highly effective conflict resolution skills


  • Driver's licence and access to a vehicle for travel throughout the HNHB LHIN area