Care Coordinator - Palliative Ontario Health Team (OHT)

at  Ontario Health atHome

Job Description:
Are you an experienced registered nurse (BScN), physiotherapist, occupational therapist, social worker, 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.
The Care Coordinator, Palliative OHT is responsible for collaborating with patients and their families/caregivers to develop quality, timely and cost-effective individual plans for service provision, based on patient needs, utilizing a multi-disciplinary approach to achieve optimal health outcomes. In supporting the development of a robust coordinated care plan, the Care Coordinator (CC) may connect the patients to additional resources and supports in the broader system.
The purpose of this position is to assist patients in safely achieving their highest level of functioning and independence, consistent with their values, priorities, capacities and preference of care. Care Coordinators will collaborate with patients, hospitals, primary care providers, service provider organizations, and community support service organizations to plan and deliver care and ensure patients are connected to other supports. In accordance with the Connecting Care Act, 2019 and its regulations, the Care Coordinator assesses patient needs, determines eligibility for services, plans and implements care, helps coordinate service delivery with an inter-disciplinary team, and reviews patients’ care plans as required to ensure needs are being met to achieve their goals of care. Care Coordinators will also carry out their duties in accordance with OHaH policies and the Leading Project OHT’s policies, procedures and parameters relating to the delivery of Care Coordination functions including mandatory points of consultation, communication and collaboration with the other members of the integrated care team.
Care Coordinators report to a OHaH Patient Services Manager for employment-related matters and are accountable to the Leading Project OHT for advancing integrated, team-based care.
With shared accountability between OHaH and the OHT, and with clearly defined models of home care planning, policies, service allocation and delivery informing accountability, roles and responsibilities, Care Coordinators connected with an Ontario Health Team Leading
Project will work as part of an integrated care team with OHT partners to carry out care coordination functions. As an integral member of the integrated care team, the Care Coordinator will contribute to the testing of home care models that improve integration, access, and patient outcomes and experience. Leveraging the key activities of care coordination, the OHT LP CC will help to inform potential scale and spread of new models of home care, including system processes and supports. Through the LP, the CC will contribute to building OHT and health system capacity for home care planning, delivery, and integration.
Mississauga OHT Leading Project Details:

In addition to Care Coordination duties outlined in the Care Coordinator job description, the role may include, but not be limited to the following:

• Assess the health status of the patient, including but not limited to ESAS and PPS
• Initiate Goals of Care discussions and End of Life planning
• Educate on “What to expect with regards to Palliative Care and EOL” including palliative resources available
• Provide Pain and Symptom Management by being familiar with contents of Symptom Management Kit and other prescribed medications
• Administer other medications as prescribed via prescribed route
• Educate patient and family re: use of narcotic medication and other medications
• Initiate and monitor CAAD PCA Pump
• Complete a medication reconciliation (MedRec)
• Administer IV hydration as per medical orders including IV start if required
• Educate & support patient and family with new IV/ injectable meds & assess ongoing needs.
• Complete Do Not Resuscitate (DNR) and Planned Death At Home (PDAH) form as appropriate
• Provide emotional and psycho-social support to patient and family/caregivers
• Consult with MRP and Palliative care Nurse Practitioner as required
• Empty and maintain care of drains and catheters (e.g. PleurX, Tenckhoff, etc.), as applicable
• Provide patient care as per patient’s care plan.
• Provide support to patient/family for Medical Assistance in Dying (MAID) provision as required
• Report any changes in health status to the MRP and Home and Community Care Support Services Palliative Care Coordinator
• Perform any additional tasks may be asked for you to perform that are within the CNO (RN) scope of practice guidelines according to your skills, knowledge and judgement to perform.
• Potential for shift nursing on weekends if available (see shift information below)

What will you do?

Care Coordinators will be responsible for:

• Assessing - and reassessing when appropriate - patient requirements, including through mandatory interRAI assessments, but not including additional clinical assessments and other interRAI assessments;
• Making determinations of eligibility;
• Developing care plans, and evaluating and revising them as necessary when the patient’s requirements change; and
• Terminating the provision of a service.

Care coordinators will also be responsible for working with staff of HSPs and SPOs, who may also be responsible for:

• Revising care plans (i.e. – number of visits, types of services) based on clinical expertise, within the context of the approved model of care, and in accordance with written arrangements between the Leading Project HSP and the HSP or SPO performing these care coordination functions;
• Carrying out additional clinical assessments to inform care planning, including by the OHaH Care Coordinator;
• Assessing/reassessing patient needs for other health and social services offered by the Leading Project HSP, such as mental health and addictions, housing, community supports, etc.;
• Providing information about - and referrals to - providers of other health and social services.

Care coordinator responsibilities will also include:

Identification and Engagement

• Engage and develop meaningful partnerships with health system partners involved in the patient’s care; Care Coordinators will follow the Leading Project’s policies, procedures and parameters relating to the delivery of Care Coordination functions, as outlined by the MOH, while including mandatory points of consultation, communication and collaboration with the other members of the integrated care team, as outlined by the Leading Project and as applicable, follow the policies related to the specific OHT care model;
• Respond to inquiries and requests for service in accordance with the patient’s care needs, identified risk factors, and urgency for services;
• Provide the patient with information about legislation, OHaH, LP OHT, Patient Bill of Rights and responsibilities under the Connecting Care Act, 2019, and services available;
• Problem-solve inquiries and issues with the patient’s care plan execution and service providers;
• Respect the patient’s privacy, autonomy, ethnic, spiritual, linguistic, familial and cultural differences;
• Obtain consent for the gathering and sharing of patient information;
• Apply a health equity lens with a goal to address the root causes of health inequities and recognize the impact of social determinants of health.

Patient Needs Assessments

• Facilitate needs assessment information exchange across providers in multiple settings and sectors, in the support of creating the system-wide team where all health care providers contribute to the integrated care plan;
• Determine capacity and assess for placement into long term care facilities as required, and counsel patient and family regarding the placement process; support patients and system through the crisis component of urgent placement needs;

Accessing Resources and Linking

• Provide system navigation services and referral to appropriate community organizations to support the individual needs of patient;
• Engage the patient & family and relevant health and social services stakeholders;
• Plan for patient transition from hospital to community as required.

Clinical Care

• Provide direct care responsibilities as defined by the scope of the Leading Project
• Pronouncement, DNR, Symptom Management

Community Relations

• Foster and sustain effective relationships with a broad group of system partners, including primary care;
• Engage with Health Care team members to build awareness of care coordination practice;
• Demonstrate behaviours, actions, and attitudes that are professional, politically sensitive, and consistent with OHaH vision, mission, and values and the LP OHT;
• Provide information about home and community care services to patients, families, community groups, and other health/social services providers through presentations and panel participation.

Care Planning and Coordination

• Monitor the coordinated delivery of services set out in the patient’s care plan;
• Establish care goals in the care plan in collaboration with the patient and anyone designated by the patient to ensure goals reflect the patient’s desired outcomes;
• Ensure strategies and actions outlined in the care plan are initiated and reviewed at all transition points and upon change in patient condition;
• Ensure that information is shared across multiple settings and sectors to ensure all partners in care are contributing to the success of the care plan.

Monitoring and Reassessment

• Monitor the outcome of the plan to ensure identified issues are escalated appropriately, including to primary care providers and others in the identified circle of care, at regular intervals and as emerging issues arise;
• Reassess for ongoing eligibility and continuing needs for service, progressing patients to independence when appropriate.

Resource Management and Fiscal Accountability

• Authorize home and community care service delivery in accordance with the care plan, OHaH and LP OHT policies and procedures;
• Negotiate visits frequency with patient and service providers and problem solve discrepancies regarding billing with service providers, escalating to the lead Health Service Provider within the LP OHT funded to provide home care, where necessary and appropriate.

Evaluation

• Evaluate patient satisfaction with services, and identify opportunities to improve the delivery of services, involving key team members;
• Contribute to data gathering for evaluation of Leading Project;
• Identify trends that will impact resources;
• Report patient incidents, compliments and near-miss events in the event tracking system and other identified systems related to OHT partnership.

Documentation

• Maintain patient documentation (i.e. in CHRIS, interRAI-PC, Clinical Connect, other systems) in accordance with professional documentation standards including the completion of appropriate forms;
• Document appropriately and as required in partner electronic health records;
• Maintain accurate electronic patient files.

Other Related Tasks:

• Work respectfully, positively and collaboratively within a team environment, sharing experiences and lessons learned;
• Collaborate with team members regarding coverage for patient care;
• Embody OHaH mission, vision and values and apply quintuple aim (enhancing patient experience, enhancing provider/staff experience, improving value, improving populations health, and advancing health equity) to support continuous quality improvement in daily work;
• Embody mission, vision, and values of the OHT;
• Exemplify, embrace and intentionally promote an inclusive work environment where all are meant to feel they belong;
• Continually demonstrate a commitment to create a positive culture of equity, inclusion, diversity and anti-racism;
• Implement new procedures and controls deemed necessary by management;
• Assist in the training, orientation, precepting and mentoring of peers. Acts as a resource to other LP OHT staff and members of the integrated team to assist in orientation, implementing change, and problem solving;
• Assist with projects and new initiatives as they relate to position;
• Participate on committees;
• Promote Best Practice and helps define best practices;
• Promote and supports research initiatives related to the Leading Project;
• Participate in relevant educational opportunities;
• Travel throughout the OHaH geography as required;
• Other duties as assigned.

Patient Safety:

• Promote patient safety in alignment with the Vision, Mission, Values and Strategic Directions of OHaH and the Leading Project OHTs;
• Work within the basic principles of patient safety by doing the right thing for the right client, using the right method at the right time;
• Adhere to OHT patient safety policies and procedures.

What must you have?

• Membership, in good standing, with the applicable regulatory body:
• College of Nurses of Ontario
• College of Physiotherapists of Ontario
• College of Occupational Therapists of Ontario
• Ontario College of Social Workers and Social Service Workers
• College of Audiologists and Speech Language Pathologists of Ontario
• Minimum two years recent experience in community health or a related field (acute, hospice, home and community care settings). If allied health professional, relevant clinical medical experience required.
• Palliative experience preferred.
• Community nursing experience is an asset.
• Sound knowledge of the Ontario health care system, the role of Care Coordinator as assessor and health planner, all relevant legislation and available local community resources
• Basic knowledge of and adherence to relevant legislation and regulations, including the Home and Community Care Services Regulation of the Connecting Care Act, 2019 and Personal Health Information Protection Act (PHIPA);
• Basic understanding of issues and priorities within the healthcare sector;
• Good knowledge of Home Care patient services strategies, objective, priorities
• Knowledge of direct care/case management models used in community health care organizations to support system navigation and hospital avoidance.

Clinical Skills

• Working knowledge of the nursing and palliative process, the consultation process, program planning and crisis management;
• Superior clinical assessment skills;

Administrative and General Skills and Attributes

• Knowledge of and adherence to identified OHaH and LP OHT policies, procedures and related practices;
• Solid ability to use MS Office applications (e.g. Word, Excel, Outlook, PowerPoint, etc.) and internet research skills and computer navigation is required;
• Strong understanding and commitment to quality service and best practice;
• Ability to analyze information, problem-solve and make good decisions;
• Accountable for own actions and decisions, making decisions within the scope of the position and referring issues/problems/events to the Patient Services Manager for employment related matters and referring issues related to the integrated care model to the OHT lead as required;
• Solid documentation skills (clear, thorough, accurate and timely);
• Self-directed with the ability to organize, prioritize and multi-task;
• Flexible, adaptable and responsive to change;
• Detail-oriented.

Communication & Interpersonal Skills

• Strong written and verbal communication skills;
• Courteous and respectful in all interactions;
• Understanding of and ability to practice culturally safe and trauma-informed care, particularly when serving Indigenous clients and families;
• Ability to establish and maintain a wide range of contacts with professionals and organizations within the community;
• Solid effective listening and facilitation skills;
• Ability to maintain confidential information;
• Empathy to sensitive issues;
• Ability to communicate in French or another language an asset.
• Valid driver’s license and access to a reliable motor vehicle
• Insurance that includes driving for business purposes and minimum liability of $1,000,000.
• Ability to communicate in French or other languages an asset.
• A valid driver’s license and access to a reliable vehicle
• We have a mandatory COVID-19 vaccination policy. As a condition of employment, all employees are required to submit proof of COVID-19 vaccination status prior to start date.

What would give you the edge?

• Experience working with diverse patient groups, e.g., multicultural, homeless, palliative, acquired brain injury (ABI), mental health, geriatrics, pediatrics
• Case management experience or recent related community experience
• Ability to speak French or another second language

What do we offer?

We know wellness is supported with work-life balance. In an inclusive culture committed to support your passion for continuous learning, growth and innovation, we offer:

• Attractive comprehensive compensation packages and benefits

• Valuable development opportunitiesMembership in a world class defined benefit pension plan

• Who we are
  We are Ontario Health atHome, ready to serve every person in Ontario. We partner with patients and caregivers, primary care providers, hospitals, long-term care and retirement homes, service providers and Ontario Health Teams, to deliver responsive, accessible, integrated, patient-centred care.
  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.
  Equity, Inclusion, Diversity and Anti-Racism Commitment
  Ontario Health atHome is committed to a culture of equity, inclusion, diversity and anti-racism. We are committed to attracting, engaging and developing a workforce that reflects the diverse communities we serve. We welcome and encourage applications from all qualified applicants. Accommodations for persons with disabilities required during the recruitment process are available upon request.
  We thank all applicants for their interest; however, only those selected for an interview will be contacted

In addition to Care Coordination duties outlined in the Care Coordinator job description, the role may include, but not be limited to the following:

• Assess the health status of the patient, including but not limited to ESAS and PPS
• Initiate Goals of Care discussions and End of Life planning
• Educate on “What to expect with regards to Palliative Care and EOL” including palliative resources available
• Provide Pain and Symptom Management by being familiar with contents of Symptom Management Kit and other prescribed medications
• Administer other medications as prescribed via prescribed route
• Educate patient and family re: use of narcotic medication and other medications
• Initiate and monitor CAAD PCA Pump
• Complete a medication reconciliation (MedRec)
• Administer IV hydration as per medical orders including IV start if required
• Educate & support patient and family with new IV/ injectable meds & assess ongoing needs.
• Complete Do Not Resuscitate (DNR) and Planned Death At Home (PDAH) form as appropriate
• Provide emotional and psycho-social support to patient and family/caregivers
• Consult with MRP and Palliative care Nurse Practitioner as required
• Empty and maintain care of drains and catheters (e.g. PleurX, Tenckhoff, etc.), as applicable
• Provide patient care as per patient’s care plan.
• Provide support to patient/family for Medical Assistance in Dying (MAID) provision as required
• Report any changes in health status to the MRP and Home and Community Care Support Services Palliative Care Coordinator
• Perform any additional tasks may be asked for you to perform that are within the CNO (RN) scope of practice guidelines according to your skills, knowledge and judgement to perform.
• Potential for shift nursing on weekends if available (see shift information below

Care Coordinators will be responsible for:

• Assessing - and reassessing when appropriate - patient requirements, including through mandatory interRAI assessments, but not including additional clinical assessments and other interRAI assessments;
• Making determinations of eligibility;
• Developing care plans, and evaluating and revising them as necessary when the patient’s requirements change; and
• Terminating the provision of a service

Care coordinators will also be responsible for working with staff of HSPs and SPOs, who may also be responsible for:

• Revising care plans (i.e. – number of visits, types of services) based on clinical expertise, within the context of the approved model of care, and in accordance with written arrangements between the Leading Project HSP and the HSP or SPO performing these care coordination functions;
• Carrying out additional clinical assessments to inform care planning, including by the OHaH Care Coordinator;
• Assessing/reassessing patient needs for other health and social services offered by the Leading Project HSP, such as mental health and addictions, housing, community supports, etc.;
• Providing information about - and referrals to - providers of other health and social services

Resource Management and Fiscal Accountability

• Authorize home and community care service delivery in accordance with the care plan, OHaH and LP OHT policies and procedures;
• Negotiate visits frequency with patient and service providers and problem solve discrepancies regarding billing with service providers, escalating to the lead Health Service Provider within the LP OHT funded to provide home care, where necessary and appropriate

Other Related Tasks:

• Work respectfully, positively and collaboratively within a team environment, sharing experiences and lessons learned;
• Collaborate with team members regarding coverage for patient care;
• Embody OHaH mission, vision and values and apply quintuple aim (enhancing patient experience, enhancing provider/staff experience, improving value, improving populations health, and advancing health equity) to support continuous quality improvement in daily work;
• Embody mission, vision, and values of the OHT;
• Exemplify, embrace and intentionally promote an inclusive work environment where all are meant to feel they belong;
• Continually demonstrate a commitment to create a positive culture of equity, inclusion, diversity and anti-racism;
• Implement new procedures and controls deemed necessary by management;
• Assist in the training, orientation, precepting and mentoring of peers. Acts as a resource to other LP OHT staff and members of the integrated team to assist in orientation, implementing change, and problem solving;
• Assist with projects and new initiatives as they relate to position;
• Participate on committees;
• Promote Best Practice and helps define best practices;
• Promote and supports research initiatives related to the Leading Project;
• Participate in relevant educational opportunities;
• Travel throughout the OHaH geography as required;
• Other duties as assigned