Working Here at St. Michael's Hospital

You are viewing a vacancy at St. Michael’s Hospital, now a member of a new health network along with Providence Healthcare and St. Joseph’s Health Centre. Together, we are committed to a shared purpose of advancing the health of our patients and our urban communities.

Care & Transitions Facilitator Therapeutic Endoscopy

Competition #:839389

Job Title:Care & Transitions Facilitator Therapeutic Endoscopy

Job Category:Nursing

New Work Type:Part-Time Permanent

Positions Available:1

Union Affiliation:ONA

Posted Date:11/06/19

Closing date:18/06/19

Salary Range:To Be Determined

FTE Assignment (Cas=0.000001):0.5

The Care & Transitions Facilitator is a practitioner in the Specialized Complex Care /Therapeutic Endoscopy program that is results oriented and committed to enhancing  the quality of cancer patient care within a complex health, social and fiscal environment.  As a clinical expert,  in conjunction with the inter-professional team, you will  be instrumental in ensuring  continuity of care and support for cancer patients during the initial phase of diagnosis and treatment. Coordinating timely, seamless and integrated care is the overarching focus of this role as the individual oversees the patient's flow throughout the assessment process and entry to the treatment phase of care.  

Other duties include:

  • Offering support and education for patients/families.
  • Coordinating multiple referrals;
  • Minimizing wait times for diagnostic treatment and planning phase
  • Streamlining/tracking processes for patient flow through the diagnostic and treatment planning phase
  • Proactively identifying system issues/opportunities for improvement  


Care Facilitation:

  • Assess the needs of patients and families working to advance all patient journeys in order to reduce delays in service/disposition
  • Ensure development, implementation and evaluation of intra-disciplinary care plans for patients with clear treatment goals including schedules/routines
  • Coordinate clinical resource use for exceptional and complex patients
  • Communicate effectively with medical/interdisciplinary/unit teams and patients/families adjudicating daily plans of care to enrich patient progress
  • Coordinate care delivery with internal and external stakeholders liaising with outside agencies to facilitate the initiation of timely and appropriate medical, functional and rehab services
  • Advocate for patient services needed for a safe and effective patient transition
  • Negotiate with reluctant or challenging patients for limited services or space
  • Identify patient care/safety issues working to resolve issues and communicate concerns to the unit Clinical Leader Manager (CLM)
  • Utilize expert knowledge and leverage external resources to reduce system barriers and facilitate safe and timely discharges as required
  • Under the direction of the CLM, act as a resource for patient care issues and problem solve in collaboration with cross program and community teams to ensure effective and efficient patient access, flow, and transitions in care   

Quality Improvement/Research: 

  • Support the CLM and team in the implementation of unit/program based quality improvement initiatives
  • Facilitate a multidisciplinary approach to quality and cost-effective complex patient care in the acute setting
  • Identify/analyze care practices & system processes that contribute to/impede outcomes and make recommendations related to evaluation and redesigning processes 
  • Update knowledge by participating in educational opportunities, reading professional publications, maintaining personal networks, participating in professional organization 


  • Regulated Health Professional with a Bachelor of Science Degree in Nursing/Health Discipline required
  • Registration in good standing with a regulatory college is required
  • Minimum 5 years’ experience working in acute care medicine setting
  • Expert skills in system navigation across the continuum of care (within TCLHIN and beyond)
  • Experience in partnership development within acute care and community agencies
  • Adept at managing challenging conversations related to patient care and/or disposition (with health care providers and with patients and families)
  • Demonstrated ability to recognize gaps in organization and system performance to identify trends and opportunities for improvement and access to care (micro and macro level)
  • Demonstrated ability in problem solving
  • Excellent communication, facilitation and negotiation skills
  • Demonstrated ability to facilitate effective teamwork among a group of multi-disciplinary professionals
  • Proven ability to plan, organize and coordinate various activities
  • Demonstrated ability to manage competing priorities and balance multiple, disparate tasks
  • Proficiency in the use of computers with proven experience in data interpretation and extraction of information 

NOTE: Please note all unionized and non-unionized candidates are welcome to apply. Should a Registered Nurse be the successful candidate, the position will be in accordance to the ONA collective agreement.