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Job Number: J1020-0180

Job Title: Coordinator- Community Reintegration (CEN)

Department: RVC 3MBW CCC

Job Category: Clinical Professional/Allied Health

Hospital Location: Centenary

Job Type: Temporary Part Time

Contract Duration: 6 months

Number Of Positions: 1

Union: Non Union

Hours: Days


Across our three hospitals and eight satellite sites, Scarborough Health Network (SHN) is shaping the future of care. Our many programs and services are designed around the needs of one of Canada’s most vibrant and diverse communities. We are home to North America’s largest nephrology program, as well as the designated cardiac care and spine centre for Scarborough and surrounding communities to the east. We are proud to be a community-affiliated teaching site for the University of Toronto and partner with a number of other universities and colleges, helping to train the next generation of health care professionals. Learn more at

The completion of this online form serves as your application and will be used to determine if you meet the requirements of this position. Please ensure that you have provided all pertinent information necessary to be considered for this vacancy by the close date.

Reporting directly to the Manager, Medicine, Transitional Care & Senior′s Health the coordinator will work with all identified stakeholders to ensure a smooth transition from hospital to community, with supports occurs.

The Community Re-integration Coordinator oversees, educates and coordinates with patients and their caregivers on the supports available under the community reintegration project, in partnership with Scarborough Centre for Health Communities (SCHC)
The incumbent will interact with clients, caregivers, front line staff as well as management staff at SHN and SCHC to ensure timely, efficient and effective submission of requested services for a smooth transition into the community.

The incumbent in collaboration with SHN and SCHC leadership will expand access to day programs and community services post discharge. They will assist in finalizing the development:
1. Pathways for patients and caregivers for this program
a. Ensure process to coordinate post discharge support through Virtual Ward Navigator
b. Refining program criteria and patient needs stratification along with service bundles
2. Refine the role of coordinator which oversees program and patient outcomes
3. Develops engagement and communication strategy, along with communications
4. Review privacy, consent and process to attend program
a. Engage risk management, privacy and physician leads
b. Review transfer of accountability process
5. Establish funds transfer process and service reconciliation
a. Develop reconciliation reports of service and funding
6. Review and keep updated the evaluation framework for the program.
a. Meet at a mutually agreeable time with SCHC on a bi-weekly basis to ensure Key performance indicators are established and reduce any potential barriers for success.


• Current registration from Professional College
• P.I.E.C.E.S., GPA, Montessori-based Dementia Programming training certifications or certified by March 31st 2021
• Member of Professional Association
• Minimum of three years′ recent experience in specialized geriatrics - assessing, treating and developing care plans for older adults with dementia, neurodegenerative conditions, mental health or addictions issues who exhibit responsive behaviours
• Extensive clinical knowledge and skill (understanding diagnosis, signs and symptoms, treatment) as they apply to the older adult
• A well-developed clinical understanding of dementia and fragility and the ability to appreciate the unique impact of the disease (i.e. amnesia, agnosia, aphasia, altered perception etc.) on the person and their support system, and the ability to creatively intervene to support them.
• Demonstrate thorough knowledge of home and community based care practices, community and multi-disciplinary resources and possess the ability to provide linkage to the appropriate services necessary to best serve the person
• A proven ability to liaise with referral sources and other community agencies to promote effective inter-collaborative communication and positive relations among care partners
• Excellent organizational, interpersonal, problem solving and decision-making skills
• Recent experience in supporting point of care clinical staff
• Demonstrates values consistent with SHN′s Code of Conduct and is committed to fostering a healthy and positive work environment in accordance with Health & Safety policy and legislation
• Utilize protective equipment provided and identify and reports hazards
• Engages in ethical conduct and strives to understand and appreciate the diversity of our patient/staff population and community
• Excellent work performance and attendance


• Current certification in Geriatrics
• Experience working in both acute care and community care

Scarborough Health Network (SHN) embraces and celebrates our community’s unique multicultural heritage and diversity. SHN is an equal opportunity employer, dedicated to a culture of inclusiveness and diversity reflecting our diverse patients, staff and community alike. We are committed to providing barrier-free and accessible employment practices in compliance with the Accessibility for Ontarians with Disabilities Act (AODA). Should you require accommodation through any stage of the recruitment process, please make them known when contacted and we will work with you to meet your needs.

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