Support a Mission-Driven Team as Director, Transitions & Integrated Care
CANES Community Care is a not-for-profit organization committed to providing outstanding support and care services that enhance the lives of seniors, enabling them to remain in their homes and communities. Guided by our vision — Live well, age well – with CANES Community Care — we foster a workplace culture rooted in our core values: Reliable, Reputable, Responsive, and Reaching.
About the Role:
POSITION SUMMARY:
The Director, Transitions & Integrated Care provides strategic, tactical and operational leadership to client services teams and leads the development and implementation of the integrated care, carebridge and transitional care program. This role is responsible for designing and optimizing a comprehensive integrated client-centered model of care that brings together interdisciplinary services including nursing, care navigation, recreational therapy, transportation, personal care, social work, primary care, and community supports. The role oversees and monitors financial and performance objectives, takes corrective action as needed, and ensures accurate reporting to funders. The Director participates in research and promotes leading practices to support continuous improvement across client services. They advise the Vice President (VP), Client Services on the impacts of external changes from a client services perspective and collaborate closely with the Senior Director, Community Support Services, departmental leads, and cross-functional teams to support daily operations, drive innovation, and enhance service delivery.
KEY RESPONSIBILITIES:
Client Programs and Services
· Participates in research, environmental scans, and needs assessments to design an integrated model of care grounded in leading practices, population needs, and system priorities.
· Lead the development and execution of an integrated care model with the VP, Client Services that aligns with CANES vision and population health needs.
· Identify opportunities to enhance care coordination and reduce fragmentation across the health care system through an integrated model of care that brings primary care, nursing, CANES current programs/ services such social work, recreational therapist, transportation, care navigation.
· Develop a coordinated, scalable care framework that strengthens transitions, continuity, and integration across programs including Transitional Care, Integrated Care, and Carebridge.
· Establish a long-term roadmap for integrated care, incorporating evidence-based practices, innovation, and continuous improvement.
· Assists in applying for new funding by providing input/writing and reviewing the business cases for the agency.
· Reviews and establishes collaboratively with the VP Client Services performance targets, performance indicators, and staffing requirements for both existing and new client services programs.
· Builds and maintains strong partnerships with external stakeholders, including Ontario Health, Ontario Health@Home, Ontario Health Teams, primary care providers, community partners and hospital discharge planners.
· Partners with the VP Client Services and Senior Director, Community Support Services, to ensure appropriate clinical policies/ procedures and risk management practices are in place to support safe, high-quality clinical services.
· Oversee the implementation of program initiatives, ensuring alignment with timelines, resources, and expected outcomes.
· Lead interdisciplinary teams and program managers to deliver coordinated client-centered care.
· Collaboratively design and operationalize workflows, protocols, and care pathways to enable effective collaboration and seamless transitions.
· Analyze data related to client complaints, adverse events, medication errors, and other quality and safety indicators to identify trends and drive improvement initiatives.
· Implement applicable legislative and regulatory changes, ensuring staff are informed, trained, and compliant.
· Provide coaching, direction, and support to staff in day-to-day program delivery and decision-making.
· Provide ongoing reporting to the VP Client Services and funders on a monthly, quarterly, and annual basis.
· Develop and implement semi-annual training plans, including reviewing materials and facilitating training to support program quality and staff competencies.
· Proactively identify risks and facilitate timely resolution of issues.
Organization and Administration
· Lead and support accreditation activities, including preparation, policy and procedure updates, staff engagement, and adherence to regulatory and quality standards related to their programs.
· Responsible for the retruitment and management of program managers, supervisors and other team members.
· Responsible for preparing staff work schedules.
· Responsible for performance management of direct reports
· Approves or denies requests for vacation and leaves of absences for direct reports
· Contributes to a culture of client safety and employee Health and Safety, by complying with all safety practices of the organization, reporting unsafe practices and adverse events, and acting on safety recommendations
· Promotes proactive Health and Safety practices within program operations
· Keeps updated on all OSHA legislation and observes, practices and enforces appropriate procedures in regard to Fire, Safety, Quality and Environmental Standards
· Ensures compliance with all organizational policies, including but not limited to workplace conduct, health and safety, privacy, and workplace violence and harassment policies
QUALIFICATIONS:
· Post-secondary school degree in a health-related discipline
· Registered Nurse (RN) designation strongly preferred; consideration will be given to candidates with relevant regulated health professional credentials in good standing
· Minimum 5 of experience in a management position within the healthcare sector
· Minimum of 10 years in the health care industry
· Experience in developing and implementing quality initiatives
· Knowledge of the OH&S Act & Regulations
· Proficient in MS Office suite products with strong computer skills
· Experience and knowledge of gerontology
· Excellent oral communication, organization and writing skills
· Clear Police Reference Check with Vulnerable Sector Screening
· Valid class G driver’s license and access to reliable vehicle
· Strong problem-solving, teamwork and interpersonal skills
· Experience in the development of policies and procedures, including familiarity with applicable legislation and governing/regulatory bodies
· Knowledge of various CQI models and frameworks, including the Model for Improvement (with Plan-Do-Study-Act), Lean, Six Sigma and Baldrige Award Criteria
· Experience working in a public health setting
· Experience with client relations, including liaising with internal and external teams
This job description outlines the principal duties of the role and is not exhaustive. Other duties may be assigned as operational needs require.
Compensation Details
We do not use AI for recruitment, all applications and interviews are reviewed by our Talent Acquisition team. This role is a new position. The total compensation for this position is $100,000 - $130,000. The compensation offered is determined based on the successful candidate’s relevant experience, skills, and competencies, taking into consideration internal equity.
CANES Community Care is an equal opportunity employer committed to fostering a diverse, inclusive, and barrier-free workplace. We welcome applications from all qualified individuals and strive to attract, develop, and retain talent from a wide range of backgrounds, experiences, and perspectives.
In accordance with the Accessibility for Ontarians with Disabilities Act (AODA), accommodations are available upon request throughout the recruitment and selection process. If you require any accommodations, please let us know and we will work with you to meet your needs.
Job Type: Full-time
Pay: $100,000.00-$130,000.00 per year
Benefits:
- Dental care
- Employee assistance program
- Extended health care
- Life insurance
- Paid time off
- RRSP match
Application question(s):
- What are your salary requirements?
- Are you a regulated health professional, in good standing with your College? (RN, OT, Etc)
Work Location: In person
