St. Joseph’s Healthcare Hamilton (SJHH) and the Hamilton Niagara Haldimand Brant (HNHB) Local Health Integration Network (LHIN) are committed to patient centered transitions comprised of a coordinated, interprofessional approach from the time of presentation and/or admission through to discharge to the community. SJHH and the HNHB LHIN have a joint responsibility to the community to optimize the appropriate use of hospital resources ensuring beds and services are available for patients requiring hospital care. Establishing a SJHH & HNHB LHIN interprofessional 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 SJHH & HNHB LHIN, the Integrated Manager of Transitions of Care is committed to providing outstanding care - Every person, every day and will embrace the following values: respect, integrity, caring, innovation, accountability, transparency, collaboration, real conversation.
With joint accountability to the SJHH Clinical Director, Community Partnerships & Corporate Alternate Level of Care and the HNHB LHIN Director, Patient Care, the Integrated Manager of Transitions of Care will provide operational leadership in the effective transition/discharge of patients from SJHH (inpatient and Emergency Department) to the community.
The SJHH/HNHB LHIN Integrated Manager of Transitions of Care will directly lead identified SJHH staff whose function focuses on discharge/transition planning and HNHB LHIN staff assigned to SJHH. 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.
The SJHH/HNHB LHIN Integrated Manager of Transitions of Care will work collaboratively with: SJHH Clinical Managers responsible for the Emergency Department, inpatient units and their teams including Physicians; HNHB LHIN Home & Community Care Managers and their teams, Primary Care, Community partners and relevant Professional Practice Leads to achieve outcomes such as: a reduction in the length of time people are spending in the emergency department/hospital, the prevention of avoidable re-admissions to hospital, a reduction in the number of people waiting in hospital beds for the right level of care, and to ensure patients who require a discharge plan have and can identify a single point of contact to support their discharge.