Care Coordinator

3 months ago

Mississauga, Canada Ontario Health atHome Full time

**Job Description**:
Are you an experienced registered nurse (BScN), physiotherapist, occupational therapist, social worker, or speech language pathologist seeking a rewarding career that cares for others, in a professional practice that cares for you? You’re looking in the right place.

The **Care Coordinator, Palliative OHT** is responsible for collaborating with patients and their families/caregivers to develop quality, timely and cost-effective individual plans for service provision, based on patient needs, utilizing a multi-disciplinary approach to achieve optimal health outcomes. In supporting the development of a robust coordinated care plan, the Care Coordinator (CC) may connect the patients to additional resources and supports in the broader system.

The purpose of this position is to assist patients in safely achieving their highest level of functioning and independence, consistent with their values, priorities, capacities and preference of care. Care Coordinators will collaborate with patients, hospitals, primary care providers, service provider organizations, and community support service organizations to plan and deliver care and ensure patients are connected to other supports. In accordance with the _Connecting Care Act, 2019_ and its regulations, the Care Coordinator assesses patient needs, determines eligibility for services, plans and implements care, helps coordinate service delivery with an inter-disciplinary team, and reviews patients’ care plans as required to ensure needs are being met to achieve their goals of care. Care Coordinators will also carry out their duties in accordance with OHaH policies and the Leading Project OHT’s policies, procedures and parameters relating to the delivery of Care Coordination functions including mandatory points of consultation, communication and collaboration with the other members of the integrated care team.

Care Coordinators report to a OHaH Patient Services Manager for employment-related matters and are accountable to the Leading Project OHT for advancing integrated, team-based care.

With shared accountability between OHaH and the OHT, and with clearly defined models of home care planning, policies, service allocation and delivery informing accountability, roles and responsibilities, Care Coordinators connected with an Ontario Health Team Leading

Project will work as part of an integrated care team with OHT partners to carry out care coordination functions. As an integral member of the integrated care team, the Care Coordinator will contribute to the testing of home care models that improve integration, access, and patient outcomes and experience. Leveraging the key activities of care coordination, the OHT LP CC will help to inform potential scale and spread of new models of home care, including system processes and supports. Through the LP, the CC will contribute to building OHT and health system capacity for home care planning, delivery, and integration.

Mississauga OHT Leading Project Details:
In addition to Care Coordination duties outlined in the Care Coordinator job description, the role may include, but not be limited to the following:

- Assess the health status of the patient, including but not limited to ESAS and PPS
- Initiate Goals of Care discussions and End of Life planning
- Educate on “What to expect with regards to Palliative Care and EOL” including palliative resources available
- Provide Pain and Symptom Management by being familiar with contents of Symptom Management Kit and other prescribed medications
- Administer other medications as prescribed via prescribed route
- Educate patient and family re: use of narcotic medication and other medications
- Initiate and monitor CAAD PCA Pump
- Complete a medication reconciliation (MedRec)
- Administer IV hydration as per medical orders including IV start if required
- Educate & support patient and family with new IV/ injectable meds & assess ongoing needs.
- Complete Do Not Resuscitate (DNR) and Planned Death At Home (PDAH) form as appropriate
- Provide emotional and psycho-social support to patient and family/caregivers
- Consult with MRP and Palliative care Nurse Practitioner as required
- Empty and maintain care of drains and catheters (e.g. PleurX, Tenckhoff, etc.), as applicable
- Provide patient care as per patient’s care plan.
- Provide support to patient/family for Medical Assistance in Dying (MAID) provision as required
- Report any changes in health status to the MRP and Home and Community Care Support Services Palliative Care Coordinator
- Perform any additional tasks may be asked for you to perform that are within the CNO (RN) scope of practice guidelines according to your skills, knowledge and judgement to perform.
- Potential for shift nursing on weekends if available (see shift information below)

What will you do?

Care Coordinators will be responsible for:

- Assessing - and reassessing when appropriate - patient requirements, including through mandat

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