Care Coordinator, Primary Care

4 weeks ago

Toronto, Canada CommunitiCare Health Full time

**JOB POSTING: Permanent Part-Time Primary Health Care Coordinator**

Job ID: CCH-2410

Bargaining Status: C.U.P.E. Local 4891

Hours of Work: Monday to Friday, 21 hours per week, at least one evening per week is required

Service Area: Primary Care

Reports To: Director of Primary Care

**Salary**: $37,233 - $44,859.60 per annum, plus 12 paid vacation days, 6 paid professional development days, excellent benefits

Start Date: Summer 2024

**About CommunitiCare Health**

We are a community health care agency that provides a full range of community health care and support services, making us a distinctive agency in Toronto offering a blend of community support services, community mental health and addictions services, supportive housing, inter-professional primary care and home care services. We are community governed. We continually look for ways to serve our clients and our community better and to provide enhanced access to equitable care. We are looking to expand our Primary Health Care team with the addition of a new Primary Health Care Coordinator.

We have a committed team of professionals - family doctors, nurse practitioners, registered nurses, chiropodists, physiotherapists, occupational therapists, dietitians, social workers, therapists, community health workers and administrative staff. As a valuable member of our inter-professional primary health care teams, the Primary Health Care Coordinator works closely and in collaboration with all primary care providers within Four Villages. We are seeking an experienced Registered Nurse to fulfil this role and as a key member of our inter-professional teams. This is a unionized position.

**Position Statement/Summary**

This is an innovative role seeking to evolve the way in which Primary Health Care Services are provided in Ontario through streamlined and coordinated care with the Toronto Central LHIN. The Primary Health Care Coordinator actively collaborates with clients, caregivers, primary care, and allied providers within the organization and with external partners. This position will develop and execute _coordinated care plans _(CCP) based on client care goals to improve the care/supports for those clients with complex health needs to help maintain their well-being and independence in the community. The Primary Health Care Coordinator, with the assistance of Community Health Workers, mental health case managers and Toronto Central LHIN home and community care staff for wider system navigation, supports and coaches clients and their families/support persons in actively coordinating care within Four Villages as well as externally with other agencies. In addition, the Primary Health Care Coordinator creates formalized care teams consisting of multiple types of providers both internal and external to Four Villages. The Primary Health Care Coordinator also functions as a liaison between internal and external service providers, specialty medical clinics and the client and their family/support person.

The Primary Health Care Coordinator works within a framework that appreciates the impact of the social determinants on wellbeing and health as well as places an active emphasis on disease prevention and health promotion.

**Key Responsibilities**
- Coordinate client care on an on-going basis:

- Develop comprehensive coordinated care plans (CCPs), taking a dynamic approach.
- Be the point of contact for clients with respect to any care coordination issues and health needs.
- Ensure implementation, evaluation, and revision of the CCPs, while monitoring care and progress towards goals and advise care team members of any new information as relevant to their role in the care for the client.
- Engage the formalized care team as required to manage care transitions or address changes in care status or client needs.
- Provide support and guide clients in making appropriate decisions to enable independence through various communication and coaching methods.
- Offer emotional support to clients and their families/support person.
- Works closely with care coordinators, case manager and mental health partners to ensure coordinated, quality, and timely care and follow-up.
- Performs physical assessments, treatment, triage, health education, and other clinical activities, for care coordination clients, according to the College of Nurses of Ontario standards and full scope of nursing practice.
- Assist Four Villages’ providers in identifying complex clients requiring CCPs.
- Reach out, connect with and support Four Villages’ clients experiencing high clinical health service utilization to better support them through inter-professional care (internal and external) via CCPs.
- Ensure effective referral relationships across community agencies, social supports, and other service providers.
- Facilitate positive relationship building and communication between clients, families, support person and their providers.
- Provide education to the clients and training to Four Villag

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