POSITION OVERVIEW:

Reporting to the CEO; the Enhanced Care Coordinator (ECC) works as a member of a multidisciplinary professional team at Scarborough Health Network. The Coordinator contributes to team decisions for individualized discharge planning in assessment, implementation and evaluation of appropriate community support services to enable the safe and effective discharge of medically stable hospitalized patients. Creative problem-solving is required to identify and eliminate or manage barriers to safe and timely discharge from hospital. Candidate must be comfortable working on their own, as they will be working off site.
The Enhanced Care Coordinator develops and supports systems and processes to ensure coordination with TransCare® Community Support Services (CSS) being designated as Lead Agency for Scarborough CSS. The ECC maintains good working relationships with our Scarborough CSS partnering organizations and provides support and guidance to staff to ensure the program mandate is met; and participates as an effective member with Home and Community Care, hospital teams as well as patients and their families.
The Enhanced Care Coordinator works closely with the Supported Referral initiative, the Home at Last (HAL) Program, Home to Stay and In-Home Services to seamlessly coordinate and schedule patient care needs.
The Enhanced Care Coordinator also provides case management for transition of services from Home First to private pay and makes necessary linkages and referrals to other organizations.

WORK CONDITION AND PHYSICAL CAPABILITIES:

· Monday to Friday from 8:30 to 4:30 with occasional evenings or weekends as required, primarily at hospital site and occasionally at Head Office when required;
· General office environment;
· Visits to client homes and exposure to various living environments, such as hoarding or infestation;
· Significant amount of computer and telephone use;
· Can lift &/ or carry 6-13.5kg (15-30 lbs).

· Conduct patient visits and attend team rounds for identification and follow up for patients to assess for eligibility;
· Participate in discharge planning meetings to coordinate community support services and contribute to decision making by the team;
· Manages services within TransCare Community Support Services’ policies, procedures and staff limitations;
· Planning, implementing and evaluating service(s) in consultation with the multidisciplinary professional team along with onsite hospital interdisciplinary teams;
· Liaising with hospitals and community organizations as required for service provision, monitoring and follow up;
· Completing verbal and written reports and presentations; maintaining statistical data and records;
· Establishing effective working relationships and maintaining appropriate community, organization and hospital contacts
· Communicating effectively in various forums
· Developing and/or assisting with program/TransCare initiatives
· Provide counseling, advocacy and support to clients with one-on-one case management;
· Crisis-intervention – follow-up on issues around neglect, abuse, mental health and emergencies;
· Perform other duties and responsibilities as directed by CEO.