Erehab Clinical Care Coordinator, Ckha

2 weeks ago

ChathamKent, Canada Home and Community Care Support Services Full time

_Are you an experienced registered nurse looking for a different kind of practice environment? You are looking in the right place._

As a valued member of our Home and Community Care team, you will facilitate the journey through Ontario’s health care system by assessing referred patients, determining their health care needs and eligibility, and ensuring they receive the services and care they need, where and when they need them.

Reporting to the Patient Services Manager, the eRehab Clinical Care Coordinator is responsible for providing a “hands-on” and an “in-home” support approach for patients who are being discharged from acute care and require in home therapy. The eRehab Clinical Care Coordinator will provide patients with timely communication and linkage to community rehabilitation therapy based on the evidence informed practice for specific disease management. The patient diagnosis/surgery will include mild and moderate stroke, Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA) and may expand include others in the future.

As an integral part of an interdisciplinary team, the eRehab Clinical Care Coordinator will develop service plans to assist patients as they recover from their acute illness or orthopedic surgery. Expected outcome is reduced acute care length of stay, emergency and hospital admissions and access to timely rehabilitation. The eRehab Clinical Care Coordinator will provide timely in-home nursing visits as required and coordinate the first interdisciplinary team visit within 72 hours from hospital discharge. The eRehab Clinical Care Coordinator will conduct a comprehensive nursing assessment, medication reconciliation using a patient centered focus and will work with the patient and their supports to develop a coordinated service plan.

What will you do?
- Develop and implement patient and family centered care plans that support transition from various acute and sub-acute environments to home care site
- Conducts clinical nursing assessments and provides supplemental information as it relates to services and resources available in the community to assist the patients
- Develops collaborative working relationships with hospital partners and enhances existing work relationships with a broad range of community agencies, to ensure that caregivers are linked seamlessly to community agencies that can support the patient
- Collaborates with the care team including primary care, contracted service providers and community support agencies to develop and delivery care plans that are patient centered to reduce the patient’s need to access the emergency room and hospital
- Designs, in consultation with the patient/caregiver, a coordinated service plan to meet identified needs and goals
- Based on patient’s level of need and discharge destination, provides assessment information, advice and recommendations to the receiving agency
- Authorizes all services, medical supplies and equipment necessary to achieve the established program goal; obtains special authorization as required
- Ensures the fiscally responsible use of appropriate resources to achieve the desired outcomes by mobilizing and integrating formal and informal patient support networks
- Collaborates with management team as need to collect data and reports as required
- Participate in establishing, maintaining, and monitoring standards for case management. This includes committee work and active participation and contribution to quality and educational initiatives.
- Other duties as assigned

What must you have?
- A Baccalaureate degree from a recognized university in the field of Nursing (and/or a combination of nursing education, training and experience) holding current registration with a regulated college in Ontario
- Minimum 2 years of relevant experience in a clinical setting as a Registered Nurse working in the acute care setting
- Solid knowledge of medication management and reconciliation
- Sound knowledge of the Ontario health care system and working knowledge of community resources and roles of health care professionals
- Experience working with rehabilitation patients (e.g. stroke, orthopedic) required
- Emergency/critical care and community nursing experience is an asset
- Canadian Nurses Association (CNA) certification in an area of specialty: Certificate in Geriatric Nursing (GNC), Neuroscience or Rehabilitation nursing an asset
- Licensed with the College of Nurses of Ontario (CNO)
- Superior clinical assessment skills
- Solid knowledge of health care related legislation and practices
- Knowledge of direct care/case management models used in community health care Organizations to support system navigation and hospital avoidance
- Ability to work independently
- Effective interpersonal and communications skills
- Must have a valid driver’s license and access to a vehicle

What would give you the edge?
- Ability to speak French or another second language

What do we offer?

**We know wellness is su

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