Community Wellness Hub Coordinator

1 month ago

Georgetown, Canada Links2Care Full time

***:
Under the direction of the Director, Quality & Performance, this position is responsible for helping to create effective links between appropriate health and social resources to minimize emergency room visits and hospital admissions, addressing social isolation and working with at risk individuals in the community.

This position will adopt a holistic approach in helping clients to engage pro-actively with the community, to address social determinants of health and wellness.

This position collaborates with various stakeholders, including hospital staff, primary care providers, and other community organizations, to employ a multidisciplinary approach in assisting clients with their transition between different environments. The aim is to support clients in accessing additional programs and services offered within the community.

**ROLES AND RESPONSIBILITIES**

**Client Service**:
1. Participates in the circle of care and conducts client needs assessments to identify risk factors and support client needs.

2. Links clients with community resources that have been identified during transition and as part of annual service planning.

3. Assesses risk factors and develops client Safety Plans to address the challenges that contribute to overuse of the healthcare system.

4. Develops communication plans and promotes use of community services as outlined in the client service plan.

5. Travels to other locations within the Halton region to connect with partners, programs and clients as required

6. Connects with appropriate transportation systems to plan the anticipated and ongoing transportation needs of clients.

7. Facilitates communication between clients and their families and members of the health care team.

8. Completes referral processes with clients for appropriate and applicable community support services in line with their goals of care.

9. Facilitates client meetings with community providers and advocates on behalf of clients.

10. Uses internal and external resources and other relevant discipline supports as required in order to assist with successful transitions to home and supports to live well in the community.

11. Communicates regularly with clients, care partners, hospital staff and family members as appropriate.

12. Connects with clients at home and in the community, and attends appointments with clients as required, to ensure successful transitions to home and supports to living well in the community.

13. Participates in discharge planning and provides support to clients to ensure successful integration into the community.

14. Collects information, records and maintains client files, updates client information and logs each interaction into client files.

15. Maintains client summary documentation including demographics for each client.

16. Performs activities of daily living tasks as required.

17. Follows all safety protocols when working within the community.

**Community Collaboration and Engagement**:
1. Collaborates with program team and Leader, hospitals, community partners and working groups to develop plans for gathering data/measurement indicators.

2. In collaboration with hospitals and partner organizations tracks scorecard/measurement indicators and experience surveys to assess client satisfaction from time of referral to return to community.

3. Collaborates with hospital and primary care teams to establish referral process.

4. Participates in designing, delivering and evaluating the overall program to meet the needs of clients.

5. Attends allied health team meetings to facilitate referral process and provides information regarding community services as needed.

6. Participates in training to ensure the effective use of client information systems that support client referral and community access to services and activities.

7. Works with internal and partner organizations to engage isolated clients, including seniors, in regular physical and social activities as appropriate.

8. Participates in community planning internally, with partner organizations and hospital staff in order to provide information on client services as required.

9. Participates in community engagement and advocacy to ensure inclusion and maximize independence of clients.

**Other**:
1. Participates in regular supervision sessions with direct supervisor.

2. Attends and actively participates in team meetings and training as required.

3. Works in close collaboration with the staff of the Ontario Health Team and community partners.

4. Complies with the service and agency policies and procedures as outlined in the Policies and Procedures Manuals.

5. Complies with the duties imposed by law or contract and the policies and procedures for performing the job in a safe and healthy manner.

6. Takes an active role in promoting and protecting personal health and safety and the health and safety of others, both staff and consumers (Sec.28(1)OHSA)

7. Performs other duties as assigned.

The above tasks are

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