Facilitator, Telemedicine Impact Plus (TIP)

The Facilitator, IMPACT PLUS, utilizes in-depth clinical knowledge, educator skills, research, and clinical expertise to ensure that patients with complex co-morbid conditions receive services/ coordinated care in partnership with primary care practitioners at each designated Health Link, with the ultimate goal of preventing avoidable emergency department (ED) visits and hospitalizations. The Facilitator works collaboratively with patients and their caregivers, primary care providers, inter-professional (IP) teams, and specifically with Ontario Health at Home (OHAH) coordinators to ensure that care plans are documented, shared, implemented, and monitored. Duties include proactively sourcing and pre-screening referrals for patient consultations, assisting in the identification of patients who meet the criteria to participate in the IMPACT PLUS program, and initiating patient contact within 2 days of receiving a referral. Responsibilities also involve gathering and organizing health information to share across transitions in care, performing client intake, providing comprehensive clinical assessments, and validating information to recommend clinical resources. The role coordinates case conferences, participates in care plan development, supports program development/evaluation, and ensures all documentation is completed.