Care Coordinator, Temporary Full Time, Congregate

7 months ago

Ottawa, Canada Home and Community Care Support Services Champlain Full time

Home and Community Care Support Services Champlain is one of 14 Home and Community Care Support Services organizations in Ontario. We are dedicated to ensuring our more than 64,000 patients annually receive the highest-quality health care and services at home. Our patient-care coordination teams help develop care plans for people of most ages, focused on maintaining each patient's independence and dignity. We also provide long-term care home placement services, and facilitate our patients’ access to the community-based services they need.

**Position Summary**:
Under the general direction of the Manager, Home and Community Care, the Care Coordinator acts as a single point of contact to improve collaboration and communication in congregate settings, including retirement homes. The Care Coordinator, through home visits and phone conversations, assesses the patient’s care needs and develops, implements, and updates (as required) a care plan that is informed by the patient’s health and psychosocial needs; and, where possible, accommodates patient and caregiver wishes. He/she also determines eligibility for and arranges for HCCSS-approved health care services and refers patients and caregivers to other community resources and programs.

As a member of the Congregate Care Team, the Care Coordinator plays an integral role in Retirement Homes or Aging in Place buildings. Care Coordinators partner closely with patients, families, caregivers, service providers and other community health and social service providers to support patients in their home environment. The Care Coordinator regularly participates and provides guidance in meetings with key stakeholders involved at each site and fosters active direct engagement with patients and their care partners.

**Primary Responsibilities**:

- Completes comprehensive patient assessments using a validated assessment tool, including patient’s clinical, physical and psychosocial needs, and caregiver needs
- Assesses the patient’s and caregiver’s understanding of, and learning needs related to diagnosis, treatment, available resources, illness adjustment, and coping mechanisms
- Assists patient and caregiver in setting appropriate goals (individual, joint, short or long term)
- Collaborates with patient, caregiver and the care team to develop an individualized care and service plan reflective of the patient’s identified priorities and desired outcomes; identifies strategies and resources to be used in attaining clinical outcomes
- Coordinates the delivery of home and community care services to patients and their caregivers
- Coordinates vendor and resource utilization involving medical equipment, supplies and services
- Facilitates understanding and cooperation among members of the patient’s multidisciplinary healthcare team; communicates with members of the patient’s health care team to maximize patient outcomes
- Initiates and authorizes the implementation of the care plan through contracted providers
- Provides regular reports to Physicians, service providers, patients, caregivers and other authorized parties as required
- Case documentation in accordance with Champlain HCCSS policies

**Education and Experience**:

- Registered Nurse (BScN or diploma) and registered with the College of Nurses of Ontario; or
- Degree or diploma in Physiotherapy and registered with the College of Physiotherapy of Ontario; or
- Degree or diploma in Occupational Therapy and registered with the College of Occupational Therapy of Ontario; or
- Degree in Social Work and registered with the Ontario College of Social Workers and Social Service Workers; or
- Degree in Speech Therapy and registered with the College of Audiologists and Speech-Language Pathologists of Ontario; or
- Degree in Foods and Nutrition or equivalent and registered with College of Dietitians of Ontario.
- Related professional experience (community based experience preferred) which is normally attained over a period of two years

**Knowledge**:

- Knowledge of medical diagnoses and prognoses, symptom management, and cognitive/psychiatric disorders
- Knowledge of case management principles and best practices
- Knowledgeable about resource availability, service costs, budgetary parameters
- Knowledge of relevant health care legislation
- Knowledge of care delivery in congregate settings

**Skills and Abilities**:

- Works with diverse patient groups with varying levels of comprehension and language capability
- Manages difficult conversations/situations such as advance care planning and goals of care in a healthy and effective manner
- Works effectively in both a team environment and independently as required
- Verbal and written communication skills to establish working relationships and maintain a wide range of partners (doctors, nurses, social workers, etc.) within the healthcare community
- Listening and facilitation skills to work with patients and their caregivers
- Diplomacy in dealing with sensitive and/

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