Care Coordinator - Multiple Eastern Ontario Locations

at  Ontario Health atHome

Job Description:CARE AND BE CARED FOR – THIS IS YOUR HOME
Are you an experienced registered nurse, physiotherapist, occupational therapist, social worker (RSW), dietitian, or speech language pathologist seeking a rewarding career that cares for others, in a professional practice that cares for you? You’re looking in the right place.
As a Care Coordinator, you will assess and determine patient care needs and eligibility, provide access and referrals to community services, and engage with patients, caregivers and other health care practitioners.
Whether you work in our office, in the community, or a health care facility – you will play a lead role in providing connected, accessible, patient-centered care – and be supported by our collaborative team that includes over 8,000 regulated health care and other professionals.
As a valued team member, your mission will be to help our patients be healthier at home, while you benefit from our supports for professional growth, personal wellness and work-life balance.

KNOWLEDGE:

• Knowledge of medical diagnoses and prognoses, symptom management, and cognitive/psychiatric disorders
• Knowledge of case management principles and best practice
• Knowledgeable about resource availability, service costs, budgetary parameters
• Knowledge of relevant health care legislation

SKILLS AND ABILITIES:

• Works with diverse patient groups with varying levels of comprehension and language capability
• Manages difficult conversations/situations such as advance care planning and goals of care in a healthy and effective manner
• Works effectively in both a team environment and independently as required
• Verbal and written communication skills to establish working relationships and maintain a wide range of partners (doctors, nurses, social workers, etc.) within the healthcare community
• Listening and facilitation skills to work with patients and their caregivers
• Diplomacy in dealing with sensitive and/or confidential issues
• Relationship building skills to develop and maintain health and community stakeholder partnerships.
• Working knowledge of computer software (email, internet) and Microsoft Office applications (Word, Outlook, etc.)
• A valid driver’s license and access to a vehicle is required
• Fluency in English and French is an asset.
• Vulnerable Sector Check completed within the last six months

WHY JOIN US?

If you’re interested in driving excellence in care and service delivery, and seeking an unparalleled opportunity to lead and learn, partner and connect, care and be cared for, this is your home.

WHAT WILL YOU DO?

Under the general direction of the Manager, Home and Community Care, the Care Coordinator is responsible for managing a caseload of diverse patients who are living and/or dealing with a variety of health concerns. The Care Coordinator, through in person visits, assesses the patient’s care needs and develops, implements, and updates (as required) a care plan that is informed by the patient’s health and psychosocial needs; and, where possible, accommodates patient and caregiver wishes. He/she also determines eligibility for and arranges for Ontario Health atHome Champlain-approved health care services and refers patients and caregivers to other community resources and programs.
As a member of the Community Care Team, the Care Coordinator will provide a broad scope of connection in their caseload geography, linking with care and services beyond community care while partnering closely with patients, families, caregivers, service providers and other community health providers supporting the patient in their home environment.
The Care Coordinator may also provide support to Primary Care teams strengthening the relationship and improving communication and access to care for shared patients as well as new patients.

PRIMARY RESPONSIBILITIES:

• Completes comprehensive patient assessments using a validated assessment tool, including patient’s clinical, physical and psychosocial needs, and caregiver needs
• Assesses the patient’s and caregiver’s understanding of, and learning needs related to diagnosis, treatment, available resources, illness adjustment, and coping mechanisms
• Assists patient and caregiver in setting appropriate goals (individual, joint, short or long term)
• Collaborates with patient, caregiver and the care team to develop an individualized care and service plan reflective of the patient’s identified priorities and desired outcomes; identifies strategies and resources to be used in attaining clinical outcomes
• Coordinates the delivery of Home and community care services to patients and their caregivers
• Coordinates vendor and resource utilization involving medical equipment, supplies and services
• Facilitates understanding and cooperation among members of the patient’s multidisciplinary healthcare team; communicates with members of the patient’s health care team to maximize patient outcomes
• Initiates and authorizes the implementation of the care plan through contracted providers
• Provides regular reports to Physicians, service providers, patients, caregivers and other authorized parties as required
• Case documentation in accordance with Ontario Health atHome Champlain policies