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Job Snapshot

Employee Type - Full-Time EmployeeExperience - Not SpecifiedIndustries - Health Care


Posting # 2018-832508


Position: Discharge Planner

Department: Social Work and Patient Flow

Status: Temporary Part-time for approx. 6 months (must provide availability up to 0.5 FTE)

Hours: Monday - Friday, Days, 7.5 hours

Site: Oakville

The Social Work and Patient Flow team consists of staff that provide scope of practice social work and discharge planning for all four sites of Halton Healthcare (including the Burlington Satellite Dialysis Program), and patient flow  to the Oakville site only. 


The successful candidate will work within a fast-paced environment as a collaborative team member of an interdisciplinary team. Using critical thinking and working with the interdisciplinary team, the Discharge Planner collaboratively formulates, facilitates and coordinates discharge plans focused on the needs and goals of the patient and their family system. The Discharge planner understands the Flow and Capacity challenges of a hospital system and works to achieve that the patients are in the right place, at the right time, receiving the right care. 

  • Coordination, formulation/development, documentation, and implementation of care plan for hospital discharge and safe transition back to community or institutional setting.
  • Identification of both short and long term goals to ensure/enhance continuity of care for patient/family.
  • Ensure plan is communicated to all stakeholders and that appropriate referrals have been processed and received
  • Ensure that patient and/or SDM understands the discharge plan and has the relevant contact information for community partners.
  • Ensure efficient use of hospital and community resources
  • Early identification of patients requiring complex discharge planning case management through high risk screening criteria, bullet rounds and referrals.
  • Planning which is a dynamic process and involves continuous review and communication of potential plans and time lines in partnership with the multidisciplinary team, client/SDM, family, and community agencies/facilities.
  • Facilitation of safe patient discharge through: ongoing assessment, case coordination and development of appropriate discharge plan. Included but not limited to: patient/family education; referral and completion of application to specialized treatment programs; coordination of family meetings; coordination of legal/financial capacity or SDM issues including potential PGT involvement. Participation in daily bullet rounds, twice weekly Joint Discharge Operations – JDO- meetings and (where appropriate) weekly multidisciplinary team rounds. Ongoing review and monitoring of ALC designation and discussion with SDM, family and patients regarding HHS DCP policy and related copayments; ongoing re-evaluation of discharge plan especially if other special needs identified, e.g. significant behavioral/psychiatric concerns. 
  • Advocate to identify gaps in services, need for individualized program consideration and system level changes required to meet changing needs of patient population.

Qualifications/Skills Required:

Halton Healthcare Services is seeking individuals who are leaders in their chosen profession, patient/customer focused, team players, effective communicators, caring and respectful and are fiscally responsible.

  • BScN or BSW or MSW required
  • Current registration and membership in good standing with respective regulated College (OCSWSSW, ONA)
  • 2-5 year clinical experience in an acute care hospital setting
  • Minimum of three years, including community work and/or gerontology, discharge planning
  • Current knowledge of community resources and initiative to proactively search for new resources
  • Experience with legislation that governs Public Hospitals (Public Hospitals Act, Substitute Decisions Act, Consent to Treatment Act, etc.)
  • Demonstrated extensive knowledge base of resources in the public and private sector, and medical and clinical language and procedures.
  • Extensive knowledge of how to effectively serve an increasingly aging and diverse population with complex medical, functional, cognitive and psychosocial needs
  • Comprehensive knowledge of the impact of social determinants of health on discharge planning, hospital LOS, Patient Flow and hospital system capacity
  • Expert communication, collaboration, organizational and problem solving skills
  • Ability to work independently as well as with an interdisciplinary team
  • Demonstrated ability to set priorities
  • Skilled working with a broad range of client groups and their significant supports
  • Satisfactory employment and attendance record

Posting Date: October 18, 2018

Internal applications due by: October 25, 2018

If you are passionate about what you do, motivated by a job well done, and as committed to excellence, quality and patient satisfaction as we are, we'd like to hear from you.  Please submit your application via our website at directly to this posting and include a current copy of your resume. 

We thank all those who apply but only those individuals selected for further consideration will be contacted.  

In accordance with the Accessibility for Ontarians with Disabilities Act and the Ontario Human Rights Code, Halton Healthcare will provide accommodations throughout the recruitment and selection process.  If you require an accommodation, we will work with you to meet your accommodation needs to ensure your equal participation.

All personal information is collected under the authority of the Freedom of Information and Protection of Privacy Act.

Halton Healthcare is a smoke free facility in and around all three sites. Smoking is not permitted on hospital properties. We thank everyone who works at or visits our hospitals for respecting this healthy initiative. We are also a scent-free environment for all employees and visitors to accommodate individuals’ health concerns arising from exposure to scented products, We ask for everyone's cooperation in our efforts to accommodate health concerns.

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