Coordinator Frailty Identification & Transition

Thunder Bay, ON

JOIN OUR TEAM AND HELP LEAD WITH CARE, COMPASSION AND COMMITMENT!

ABOUT THE ROLE

Under the direct supervision of the Director Inpatient Rehabilitative Care, the Coordinator – Frailty Identification and Transition Coordinator (FIT Coordinator) is embedded across care settings at TBRHSC, supporting older adults (65+) from entry through the Emergency Department (ED), inpatient acute care, and transition to the most appropriate level of care. This role works collaboratively with the TBRHSC Geriatric Emergency Management (GEM) Nurses, Patient Flow Coordinators, Geriatric Clinical Nurse Specialist, Hospital Elder Life Program (HELP) team, and St. Joseph’s Hospital Geriatric Assessment and Rehabilitative Care Unit, including Geriatricians.

The position focuses on the early identification of frailty, geriatric syndromes, and restorative potential, enabling timely, patient-centered care planning and transitions. The Coordinator plays a key role in optimizing patient flow, reducing unnecessary ED visits and acute admissions, supporting restorative care, and facilitating timely transfers—targeting transitions within five to seven days of admission, where appropriate.

This role aligns with Alternate Level of Care (ALC) Leading Practices, Home First philosophy, and system flow priorities, supporting improved outcomes for older adults across the continuum of care.

HIRING DEADLINE: May 6, 2026

This job posting is for an existing vacancy currently available within our organization.

COMMITMENT TO DIVERSITY

At St. Joseph's Care Group (SJCG), our diverse workforce strengthens our ability to provide culturally competent care and innovative solutions to the complex needs of our clients and communities. We encourage applicants from all backgrounds, diverse race, ethnicity, gender identity or expression, age, sexual orientation, family status, religion, disability, and socioeconomic status, to help address under-representation and foster greater inclusivity and belonging at SJCG.

By promoting a culture of inclusion and mutual respect, we ensure that our values of care, compassion, and commitment are reflected in every aspect of our work. If you are passionate about making a difference in healthcare and are committed to upholding these values, we encourage you to apply and join us in our journey towards a more inclusive and equitable future.

St. Joseph's Care Group is committed to providing reasonable accommodations to applicants with disabilities in our job application and hiring process.

WHAT YOU BRING

Education/Experience:

• Regulated health professional in good standing (e.g., Social Worker, Registered Nurse, Occupational Therapist, Physiotherapist, or other relevant designation).
• Current registration with the applicable professional regulatory college.
• Minimum two years of experience in acute care, geriatrics, or a related healthcare setting.
• Demonstrated experience working with older adults with complex medical, cognitive, and social needs.

Skills/Abilities:

• Knowledge of geriatric syndromes, frailty assessment, restorative care principles, ALC Leading Practices, and Home First philosophy.
• Strong clinical assessment, counseling, and patient/family education skills.
• Excellent verbal and written communication skills.
• Demonstrated critical thinking, problem-solving, and conflict resolution abilities.
• Ability to work independently and collaboratively within an interdisciplinary team.
• Familiarity with community resources and care navigation across the continuum.
• Demonstrated ability to conduct comprehensive geriatric assessments and identify frailty to support individualized care planning.
• Strong systems-thinking with proficiency in optimizing patient flow across multiple care settings.
• Commitment to delivering patient and family-centred care.
• Proven capability to collaborate effectively within interprofessional teams to enhance care outcomes.
• Skilled in applying the Home First philosophy and ALC Leading Practices to promote efficient transitions and discharge planning.
• Highly adaptable and resilient in dynamic, high-acuity environments.
• Demonstrated regular attendance at work.

Conditions of Employment:

• This position shall be conditional upon a satisfactory Police Vulnerable Sector Check (PVSC) where indicated, to ensure the absence of relevant criminal convictions.
• Will be required to travel to various work locations and to provide own transportation

WHY JOIN ST. JOSEPH'S CARE GROUP

St. Joseph's Care Group (SJCG) offers a meaningful career for those seeking to make a difference in health care. As a leading provider of complex care, rehabilitation, long-term care, and mental health and addiction services, SJCG is recognized for its commitment to high-quality compassionate, and people-centred care.

Experience a rewarding career and lifestyle you’ll love at the heart of Thunder Bay! Here’s what awaits you when you join our team:

• Enjoy a Competitive, Forward-Thinking Compensation Package: We offer salaries and benefits that recognize your talent and dedication.
• Secure Your Future: Become a member of the Healthcare of Ontario Pension Plan (HOOPP) – our organization will contribute $1.26 for every $1 you invest in your pension, ensuring a strong, stable retirement for your future.
• Make Your Move Easier: We provide relocation assistance to help you settle in (some conditions apply).
• Thrive in a Supportive Team: Grow your career and make meaningful contributions alongside dedicated and passionate colleagues.
• Commitment to Diversity: We are proud to be an inclusive workplace that celebrates the unique backgrounds, perspectives, and talents of every team member.
• Advance Your Skills: Access ongoing professional development, advanced education, and a tuition loan program.
• Continuous Improvement: We foster a culture where every team member is empowered to identify opportunities for improvement and share ideas.
• Prioritize Your Wellbeing: Take advantage of comprehensive wellness initiatives and access to an Employee & Family Assistance Program.
• Shape the Future: Get involved in research and teaching initiatives that make a real difference.
• Be Recognized and Rewarded: Benefit from employee recognition, discount, and referral programs.
• Live Where Adventure Meets Opportunity: Nestled on the stunning shores of Lake Superior, Thunder Bay offers the perfect blend of vibrant city life and breathtaking outdoor escapes.

APPLICATION INFORMATION

All job postings will follow the requirements outlined in the applicable collective agreement or the Terms & Conditions of Employment. If the job is not filled through this process, the posting will remain on our external site until the position is successfully filled.

Applicants who are part of the bargaining unit will be given priority consideration as set out in the relevant collective agreement. It is the applicant's responsibility to clearly demonstrate that they have the skills required for the position they are applying for.

This hiring process includes the use of AI-enabled systems for administrative and candidate management purposes.