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About the Role

The Manager, Hospital to Home and Clinical Programs leads a service team to deliver seamless and timely care for clients transitioning from hospital to home and those receiving community-based services. This role ensures the team effectively plans, organizes, implements, and delivers high-quality, responsive, and integrated care, while supporting the transitional care program and ensuring continuity across broader clinical services. The Manager develops and retains a high-performing team through strong leadership and operational oversight, driving the adoption of effective systems and processes, supporting clinical accountability, and fostering a positive workplace culture.

Responsibilities

Manage relationship building and rapport with external partners.
Provide professional leadership to service team members and ensure employees fulfill their mandate and accountabilities.
Ensure clients and their families experience high-quality, responsive healthcare service and goal-based outcomes.
Implement quality assurance and improvement programs, processes, and accountability for the team.
Work closely with the Quality team to ensure timely and accurate data collection and reporting to Sinai Health for program evaluation and improvement.
Conduct documentation audits to ensure compliance with clinical and reporting standards.
Support the development and implementation of professional practice guidelines and standards across client services.
Monitor program indicators, including time to first service, missed care, client experience, and length of stay.
Translate audit findings, client feedback, and performance trends into improvement plans with assigned responsibilities and timelines.
Report program performance, emerging risks, and corrective actions to the Director and relevant partners.
Actively develop and foster trust-based, collaborative partnerships with external key organizations, including OHAH, funders, and hospitals.
Lead weekly huddles with the Sinai Health team to provide updates on active H2H clients and discuss care plans and barriers.
Participate in case conferences with patients and families where necessary to ensure transparent care coordination.
Support smooth patient discharges and transitions to Ontario Health at Home, self-care, or long-term care.
Identify opportunities to demonstrate Circle of Care’s service assets and commitment to excellence to key partners and funders.
Lead and resolve client or family escalations, participating in challenging conversations to support service recovery and continuous improvement.
Lead recruitment, onboarding, performance reviews, and staff development with HR.
Set clear performance expectations and address practice or performance concerns through coaching and follow-up.
Develop succession plans and strengthen team capability.
Complete regular risk assessments to identify operational risks, service gaps, and anticipated increases in staffing requirements.
Collaborate with Finance to review program demands, assess financial implications, and develop proposals for additional staffing and resource needs.
Facilitate regular huddles with Rehabilitation, Nursing, and Social Work teams to ensure client goals are met and appropriate transition supports are in place.
Provide oversight and guidance to the Program Supervisor regarding caseload assignments, workload distribution, and resource utilization.
Ensure all partners supporting the program adhere to established program guidelines, eligibility criteria, service expectations, and operational standards.
Monitor program performance, client outcomes, service utilization, and staffing capacity to identify improvement opportunities.
Maintain ongoing discussions with leadership and key stakeholders regarding program needs, service pressures, and expansion opportunities.
Participate in strategic planning to support program growth, sustainability, and enhanced service delivery.
Participate in relevant conferences, meetings, and presentations to share program outcomes, best practices, and lessons learned.
Identify opportunities for continuous quality improvement and strengthen collaboration among hospital, community, and care transition partners.
Model the way for employees through personal example and a dedication to action, results, and client service excellence.
Develop and sustain a team culture that embodies open, two-way communication, client-centered focus, learning and innovation, accountability, teamwork, and continuous improvement.
Provide consistent coaching, communication, and support to front-line staff, ensuring clarity on clinical practice and program expectations.
Hold regular team meetings and training sessions to ensure ongoing staff education aligned with program needs and best practices.
Lead CRM development and improvement work to ensure the system meets program needs, supports daily workflows, and enables accurate documentation and reporting.
Actively participate in program design and development discussions, contributing operational insights and innovations.
Engage in conversations and planning related to resource optimization, including changes to staffing models.
Oversee referral intake, eligibility review, service initiation, and discharge planning.
Monitor client volumes, acuity, staffing capacity, and workload, adjusting resources as needed.
Manage program budgets within approved allocations.
Establish coverage and escalation plans for staffing shortages, service disruptions, and urgent client needs, including after hours.
Ensure services meet contractual commitments and funder requirements.
Provide hands-on support to the supervisor and team when volumes increase or coverage is limited.
Identify and report health and safety incidents and concerns in a timely manner.
Participate in health and safety processes and procedures.
Participate in maintaining a safe workplace environment by cultivating a positive safety culture and encouraging best practices.
Participate in all health and safety training initiatives on a regular basis.
Take proactive action against client incidents within your scope of practice.
Develop a plan to identify, manage and/or minimize client safety risks or situations.
Assess the severity of an adverse client safety/risk event and determine the best follow-up and develop an action plan.
Call emergency services (911) when the client is at an immediate risk of harming themselves or others, or if there is a serious injury and/or imminent harm.
Evaluate potential hazards and identify clients at risk for adverse health and safety events, taking preventative measures.
Report all safety events impacting clients, caregivers and families in a timely and honest disclosure.

Requirements

Current registration in good standing with the College of Nurses of Ontario (CNO) as a Registered Nurse (RN) or Registered Practical Nurse (RPN).
Demonstrated nursing experience in a community-based setting, such as home care, community health, or transitional care.
Understanding of leadership, change management, business systems, and processes.
Knowledge of community resources, health care, and social service systems.
Ability to travel to various worksites on a regular basis and to respond to emergency situations.
Ability to maintain confidentiality and work independently while collaborating with a multidisciplinary team.

Skills

Microsoft Office; Excel and Power Point

Location

Hybrid

Work Type

Full-Time
Permanent
Hybrid

Experience Level

Manager

Education Level

Registered Nurse (RN) or Registered Practical Nurse (RPN)

Salary/Compensations

$80,000 to $110,000 per year

Benefits

Hybrid Environment: 3 in-office work and 2 work-from-home days.
Subsidized underground parking and convenient location on subway line and GO transit.
Health and Dental Benefits: Comprehensive coverage with employer-paid premiums.
Retirement Savings Plan: RRSP program with employer and voluntary employee contributions.
Learning and Development: Paid training and professional development opportunities.

About the Company

Circle of Care is made up of staff, students, and volunteers who bring energy and purpose, every day.

Equal Opportunity

Circle of Care is committed to fostering an inclusive, accessible environment, where all employees, volunteers and clients feel valued, respected and supported.
We are dedicated to building a workforce that reflects the diversity of the communities in which we live and serve, and creating an environment where every employee has the opportunity to reach their potential.
Circle of Care seeks applicants who embrace our values of equity, anti-racism, and inclusion.
We encourage applications from candidates who have been historically disadvantaged and marginalized, including but not limited to those who identify as First Nations, Métis and/or Inuit/Inuk, Black, members of racialized communities, persons with disabilities, women and/or 2SLGBTQ+.
We are committed to an environment that is barrier free. If you require accommodation, please inform us in advance.
We welcome you to apply for this role, even if you do not meet every requirement listed.
Circle of Care may use artificial intelligence (AI) through third-party platforms, to assist in parts of the recruitment and/or selection process.