HNHB Local Health Integration Network

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Full Time Manager, Integrated Transitions in Care - Brant Community Healthcare System (BCHS)/Hamilton Niagara Haldimand Brant Local Health Integration Network (HNHB LHIN)

Full Time Manager, Integrated Transitions in Care - Brant Community Healthcare System (BCHS)/Hamilton Niagara Haldimand Brant Local Health Integration Network (HNHB LHIN)

Competition Number 
Multiple Sites (see posting for details)
Position Group 
Non Union
Closing Date 
Length of Term 
Hours of Work 
Monday - Friday, 8:30am - 4:30pm

More information about this job

Position Summary

Location: BCHS – Brant Community Healthcare System


Brant Community Healthcare System (BCHS) 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. BCHS 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 BCHS & 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 organizations the BCHS & HNHB LHIN Integrated Manager of Transitions in Care is committed to providing outstanding care - Every person, every day and will embrace the following values: respect, integrity, caring innovation, accountability, transparency and optimism. 


With joint accountability to the BCHS Director of Clinical Services and CNO and the HNHB LHIN Director of Home and Community Care, the Integrated Manager of Transitions in Care, will provide operational leadership in the effective transition/discharge of patients from the BCHS hospital sites to the community.  


The BCHS /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 BCHS.
  • 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 with BCHS Patient Relations Officer, 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 BCHS 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, aligns with BCHS 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 BCHS/HNHB LHIN priorities.
  • Assesses and identifies critical service delivery issues and risks to BCHS and recommends and/or implements service improvements as required.
  • Identifies and evaluates the hospital and community impact of proposed or implemented changes within assigned portfolio. .
  • Provides leadership in the development of communication materials to patients and families with respect to admission, hospital stay and discharge with appropriate stakeholders.
  • Ensures patient services are provided in accordance with BCHS and HNHB LHIN policies, relevant LTC Legislation, Public Hospital Act, other standards and guidelines.
  • Creates mechanisms for improved communication, decision-making, and alignment between BCHS 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 basic 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 

  • Monitors BCHS ALC performance metrics and reports variances.
  • Works collaboratively with BCHS leadership teams to strategize and implement changes to practice that achieve ALC target benchmarks
  • Participates as required with BCHS and HNHB LHIN leadership with respect to utilization/quality indicators.
  • Participates in the development of BCHS 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 BCHS/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 BCHS 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 BCHS and the HNHB LHIN’s strategic and operational planning.
  • Establishes and maintains effective working relationships across BCHS sites, other hospitals, primary care, community and stakeholders.
  • Manages the implementation and evaluation of new BCHS 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 BCHS and HNHB LHIN on local and provincial initiatives where appropriate.
  • Participates in community events, including formal presentations, to promote BCHS & HNHB LHIN objectives, activities, programs and services.


Accountability • Decision-Making


  • Accountable for staff achievement of performance standards within assigned portfolio.
  • Identifies resource requirements for input to budget planning processes.
  • Accountable for hiring new staff, providing training and development, evaluating performance, and in consultation with BCHS and HNHB LHIN Directors and HR/OD makes decisions re discipline or termination; ensures appropriate staff policies and procedures are in place, i.e. health and safety.
  • Leads and/or participates in and demonstrates an understanding of patient care and safety principles and practices. Follows all safe work practices and procedures and immediately communicates any activity or action which may constitute a risk to client or staff safety.
  • Accountable to participate in HNHB LHIN Manager on call rotation as required.



  • Decisions are made within the BCHS & HNHB LHIN overall risk management program and within established guidelines, legislation and plans


People (Leadership)


  • Manages and provides leadership for a group of staff carrying out a number of patient service delivery and discharge planning functions.
  • Works collaboratively with HR/OD in the design and delivery of discharge planning and care transitions, education, training and performance management.
  • Participates in the development of an orientation package for new employees as required.
  • Supervises, mentors, coaches and evaluates the performance of BCHS and LHIN professional and support staff based on specific performance standards and program objectives.
  • Integrated Manager of Discharge Planning and Transitions in care will provide coverage/oversight for each other during vacation and other days off.
  • Familiarity with relevant BCHS and HNHB LHIN Collective agreements.


  • 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 BCHS/Acute Care and HNHB LHIN Home & Community Care priorities, policies, practices and service standards
  • Recent experience leading quality improvement initiatives
  • Recent experience leading inter-professional team(s) through change at a system level
  • 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

Skills & Abilities

Communication/ Interpersonal Skill 

  • 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/use of personal vehicle for travel throughout HNHB LHIN area