Title: Transitional Care Assistant
Employee Working Location: In-person (Sault Ste. Marie, ON)
Employment Status: Permanent Full-time

The Canadian Red Cross (Red Cross) - an inspirational not for profit organization, helps people and communities in Canada and around the world in times of need and supports them in strengthening their resilience. As a Canada's Best Employers 2024, we are committed to having an accessible, diverse, inclusive, and barrier-free work environment.

The Transitional Care Assistant will facilitate and support client independence and safety by providing transitional services from hospital to home which reflects the unique needs of each client. The TCA will work with Caregivers, Program Coordinator, Hospital Team, and others within circle of care to mitigate risk and reduce frequency of re-admission. The TCA will engage in service planning that addresses holistically the needs of clients in a safe manner, respecting client choices.

In this role, you will:

Support of discharge planning and execution of client discharge plans to meet client transitional needs.

• Supports client safely and comfortably at discharge during the transition from hospital to client's home in accordance with established service plan and according to the Bundled Care model.
• Facilitates/arranges the client's transportation home utilizing local transportation services and/or transports clients home by driving agency vehicle when needed.
• Support clients in the comprehension and implementation of hospital discharge instructions and creates an individualized plan of care.
• Understands and performs and/or supports the client during hospital discharge processes with activities of daily living.
• Completes/arranges errands to meet client's physical needs to support their recovery at home (nutrition, medication, medical supplies, equipment, etc.) as required, in accordance with established service plan
• Plans, arranges, procures, or performs home management duties (cooking, cleaning, laundry, etc.), in accordance with established service plan and in advance of discharge when identified.
• Procures and prepares cost effective, nutritious and diet specific meals as required.
• Safely and hygienically stores and handles food.
• Supports client in accessing food, i.e., frozen meals, food bank, and/or groceries.
• Facilitates client and caregiver engagement., i.e., providing applicable information on client related issues surrounding transitions from hospital to home.
• Communicates recommendations and supports clients, care givers and those in the circle of care to address and repair safety concerns.
• Provides companionship in cases where seniors suffer from social isolation.
• Works collaboratively within the circle of care respecting confidentiality while meeting client's care goals.

Risk Assessment and implementation of holistic supports to reduce risk of hospital readmission

• Completes risk analysis of home and evaluates client's risk of Falls using standardized Risk Assessment tool. Recommends corrective action to clients and care givers to remediate risks identified
• Completes Inter-RAI PS Screening tool and escalates based on the Assessment Urgency Algorithm which determines further assessments.
• Supports clients post-discharge to remove barriers and reduce risk in accessing resources (pharmacy blister packs, assistive devices, referrals, etc.) and for follow up discharge-related appointments.
• Facilitates discharge process and connections to Community Support Services as per program guidelines utilizing standardized referral tools. (Northeast CSS referral forms, Care Dove, etc.)
• Seeks local resources to complete tasks such as obtaining quotes and timelines for solutions to address discharge barriers and intervention needs.
• Procures goods, assistive devices, purchased with client's funds or with agency funds.
• Applies knowledge of the social determinants of health and how they affect client outcomes to client's post-discharge process.
• Actively and collaboratively involves clients and care givers in assessments, goal setting, outcomes of care, and the acquisition of social supports/activities that will alleviate isolation and loneliness.
• Communicates and educates clients and care givers with respect to the importance of interventions recommended to reduce hospital re-admission or emergency room visits.
• Understanding and communicating privacy and consent to clients/caregiver and or substitute decision maker.
• Works collaboratively and cooperatively to establish positive relationships with internal (volunteers & staff) and external partners/supports.
• Accesses client health information in the Integrated Assessment Record (ON Health provincial wide client/patient health information)

Maintains a Safe Environment

• Handles and stores hazardous products safely (WHMIS)
• Maintains comfort and safety of client's immediate environment.
• Identifies and reports any unsafe or hazardous equipment and situations to Program Coordinator.
• Assists clients in implementing strategies to address and reduce safety risks.
• Takes measures to ensure personal safety.
• Takes measures to protect the health and safety of clients.
• Completes risk assessments and evaluations to identify and support client care needs and implement strategies to reduce their health and safety risks.

Communication and Reporting

• Observes, reports, and documents any concerns related to the client or their environment to the immediate Program Coordinator and participate/support Ontario's One Client Care Plan.
• Validates, respects, and adapts to the individual's communication.
• Communicates orally and documents according to standards of documentation electronically concerns, observations and/or needs of clients in appropriate database and to the Program Coordinator or designate
• Completes all required documentation and maintains standard client files (paper/electronic).
• Maintains confidentiality and requirements to acquire and maintain special clearance required by Ontario Health to access the Integrated Assessment Record
• Follow up calls or visits with client and relevant stakeholders
• Communicates with Hospital team, clinical professionals, and others within circle of care and relaying/adapting/communicating information back to client.
• Identifies, documents, and communicates best practices for client care and services to Program Coordinator.
• Supports communication between client and care giver when needed.
• Develops and maintains a positive relationship with internal teams, related organizations, community partners, and stakeholders.
• Seeks direction from Program Coordinator as appropriate

What we are looking for:

• Minimum requirement of completion of two years post-secondary education with a concentration in social services, gerontology, therapy assistance or a related field, and a minimum of three years job-related experience or an equivalent combination of education and experience.
• Working knowledge of medical terminology is required. For recruitment purposes, previous knowledge of medical and technical terminology is an asset. Successful candidates without working knowledge of medical and technical terminology will be expected to develop a working knowledge of medical and technical terminology in the role.
• Excellent computer skills: Familiarity in Microsoft Office; knowledge of CIMS and other databases is considered an asset
• Depending on geography: Fluency in both official languages would be considered an asset OR
• Fluency in both official languages is required
• Current First Aid and CPR certification.

Working Conditions:

• Full vaccination against COVID-19 is mandatory for this position and operation.
• Valid driver's license and access to a reliable vehicle. Clean 3-year driver's abstract to drive agency vehicle.
• The work is performed in an office environment, hospital setting, in community, in agency vehicle and in client homes
• As we work with and support people (managers, colleagues, beneficiaries/customers, volunteers, donors and external partners) and communities in Canada and around the world, applicants whose first language is not English may be required to perform the responsibilities of the role in English.
• Eligibility to work in Canada: At this time, we welcome applications from candidates eligible to work in Canada. If you are not a citizen or permanent resident of Canada, we encourage you to carefully review your visa to find out whether you are eligible to work in the job you are considering applying for. Refer to our FAQ for more information.
• If you are selected for this role, you will be required to complete a successful pre-employment screening process which includes a satisfactory Enhanced Police Information Check (E-PIC).

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