Dispatches from the Frontlines: From hospital to home - Shadowing a Transition Navigator

For Transition Navigator Amil Riaz, the best part of coming to work every day is knowing that he is able to help patients through times of uncertainty and ensure they experience continuity of care.

"The patients I work with can often be uncertain about where they're going to go after their stay at the hospital, and knowing that I am able to get them to their next destination successfully, whether that's rehab or home, is very rewarding," says Amil who works primarily with patients who are elderly and have mobility issues.  

In January 2018, Michael Garron Hospital introduced the role of Transition Navigator (TN). The TN helps patients and their families safely transition to their next point of care or back to the community after their stay at the hospital. They also actively collaborate with the inter-professional healthcare team. This role ensures that patients have a point of contact in the hospital who understands their unique care needs. The TN also connects with community partners such as rehabilitation centres and personal support workers to create individualized care plans for patients.

"We're here to work with patients and to hear them and listen to their input on their own care," says Amil. "The last thing I want is for a patient or their family to think we are just telling them what's going to happen. We want them to know that we [as in the whole team] is working with them towards a common goal."

In the latest episode of Dispatches from the Frontlines, MGH Vice-President Irene Andress shadows Amil and sees firsthand what he does on a daily basis to support patients and healthcare providers.