Care Coordinator

6 months ago

Whitby, Canada Home and Community Care Support Services Central East Full time

**CARE AND BE CARED FOR - THIS IS YOUR HOME**

Are you an experienced registered nurse seeking a rewarding career that cares for others, in a professional practice that cares for you? You’re looking in the right place.

Reporting to the Senior Manager, Home and Community Care, the High Intense Supports at Home (HISH) Nurse Care Coordinator is responsible for assessing patient eligibility for services/long term care placement, assessing patient care needs, and planning and authorizing service delivery to best meet the patient’s needs.

Care coordination activities will also include scheduling care conferences to conduct Coordinated Care Plans (CCP) and acting as a point of contact for contracted providers, patients and health system partners.

**What will you do**:
The HISH Nurse Care Coordinator will use their clinical knowledge to support specialized care delivery, participate in clinical rounds, obtain/monitor vital signs, and review and administer medications during home visits if immediate medical/clinical support is required.

KEY ACCOUNTABILITIES:
1. Conducts in-person case conferences with multi-system partners
2. Participates in comprehensive assessment and collaborative care plan development
3. Performs clinical assessments in the patient’s home
4. Conducts assessments utilizing the interRAI Suite of Instruments relevant to Home and Community Care
5. Coordinates the delivery of quality, cost effective, equitable and timely services
6. Performs comprehensive needs assessments for patients and their unique situations to determine eligibility of services using an established criteria
7. Provides patient services in accordance with Home and Community Care Support Services Central East policies, relevant legislation and professional disciplines
8. Acts as primary contact for patients, communicating with patients, caregivers and contracted service providers regarding service plans
9. Participates in patient care reviews and reassessments
10. Takes charge of facilitating every step of a patient’s health care experience, providing them with the right information and helping them understand and manage their short and long-term health care goals
11. In collaboration with others, ensures all patient’s needs are met and adjusts the service plan based on changes in the patient’s status
12. Maintains each patient’s record that supports ongoing assessment and monitoring, and meets the relevant discipline and standards; documents both written and electronically, in accordance with the College of Nurses and other standards to support the team
13. Counsels patients on the placement process utilizing established criteria and guidelines for patients seeking placement; obtains consent; completes functional, psychosocial, medical and financial documentation
14. Determines the patient’s continuing eligibility for services and provides counseling and referral to other providers/agencies when service is decreased or discontinued, or when additional external agency support is required
15. Conducts reassessments for patients awaiting placement
16. Promotes, educates and interprets the role and services of Home and Community Care Support Services Central East to individuals, groups and community agencies, and health care partners
17. Maintains confidentiality and privacy by safeguarding patient information in accordance with legislation, professional college standards and Home and Community Care Support Services Central East policy

**What must you have?**
- University degree preferred in Nursing, or equivalent.
- Holds current appropriate unrestricted registration as a Registered Nurse from the College of Nurses of Ontario.
- Recent (preferably within the last 2 years) working experience conducting BP monitoring, physical and clinical assessments, medication management and administration, wound care, and blood glucose monitoring.
- Knowledge of Home and Community Care Support Services Central East’s role in the community sector
- Recent community experience and adequate knowledge of community resources
- Proficiency in prioritization in a quick and concise manor
- Demonstrate excellent interpersonal, communication, and decision-making ability
- Minimum two (2) years coordination/case management/community health or related clinical experience
- Demonstrated computer literacy is required to facilitate the use of electronic patient records and assessments
- Ability to work independently and co-operatively in busy multi-disciplinary situation
- Experience working with diverse, multicultural groups (including homeless, acquired brain injury (ABI) and pediatrics)
- 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?**

Recent community experience and adequate knowledge of community resources.

Fluency in a second language is an asset.

**Hours of Work**

**Posi

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