Care Coordinator

2 weeks ago

Smiths Falls, Canada Home and Community Care Support Services South East Full time

Company Bio
Home and Community Care Support Services South East is one of 14 Home and Community Care Support Services organizations in Ontario with a focused mandate to deliver local health care services such as home and community care and long-term care home placement.

These organizations were previously known as Local Health Integration Networks (or "LHINs") at a time when they also led local health care planning and funding, and those functions are now part of Ontario Health.

Home and Community Care Support Services South East is dedicated to ensuring the ongoing delivery of local services while Ontario makes changes to improve the health care system to give patients better-connected care with health care providers working as one coordinated team in Ontario Health Teams.
The south east region extends from Brighton on the west, to Prescott and Cardinal on the east, north to Perth and Smiths Falls, and back to Bancroft. The boundaries are for funding and planning purposes only. Residents of the Home and Community Care Support Services South East can seek health care services wherever they prefer, inside or outside these boundaries.

Position Summary
Care Coordinators are responsible for patient assessment, determination of eligibility, admission, service planning and authorization, implementation, monitoring, reassessment, adjustment and discharge planning of all patient service programs (in-home and placement), including the provision of community resource information and referral. Care Coordinators are health system navigators who link patients with the right information and resources to help them achieve their short and long-term health care goals.

**Responsibilities/Accountabilities**:

- Assesses referred patients for eligibility of services utilizing established criteria;
- Assists in identifying complex patients within Home and Community Care Support Services South East in accordance with the Health Link definition of complex
- Assists ineligible patients to access information/services appropriate to their needs and provides information on community resources and assistance to access the same where required;
- Acts as primary contact for patients, communicating with patients, caregivers, contracted service providers, primary care and Health Link partners regarding service plans;
- Collaborates with the patient, caregiver and/or family, and appropriate members of the patient’s health team related to service plan development, priority determination, authorization of services, development of mutual goals, and anticipated duration of service(s) outlined;
- Provides Care Coordination for identified Health Link patients and coordinates the primary Care Coordinator assignment with applicable Health Link partner
- Coordinates the delivery of quality, cost effective, equitable and timely services;
- Collaborates with service providers and other system partners;
- Fosters overall integration with primary care to develop strong working relationships centered on integrated patient care
- Maintains patient records which support ongoing assessment and monitoring, and meets the relevant discipline and standards, and documents both written and electronically, in accordance with the College and other standards to support the team;
- Effectively communicates with all appropriate members of the patient’s healthcare team via established communication channels including case conferences and home visits to optimize care planning and appropriate services;
- In collaboration with appropriate others, adjusts the service plan based on changes in the patient’s needs;
- Conducts home visits on a regular basis and as needed in accordance with patient needs and organizational policies;
- Counsels patients on placement process utilizing established criteria and guidelines for patients seeking placement, obtains consent, completes functional, psychosocial, medical and financial documentation;
- Advocates for the patient to facilitate positive patient outcomes;
- 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 outside agency support is required;
- Conducts reassessments for patients awaiting placement;
- Discharges patient from service and redirects to/facilitates alternative resources, if applicable and assists with access such services, if needed by the patient;
- Promotes, educates and interprets the role and services of Home and Community Care Support Services South East to individuals, groups and community agencies, and health care partners;
- Participates in data collection activities as required;
- Assists with the orientation of new staff/students and carries out preceptor responsibilities as required;
- Maintains confidentiality and privacy by safeguarding patient information in accordance with legislation, professional college standards and Home and Community Care Support S

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