Coordinator – Southlake@Home

4 weeks ago


Newmarket, Ontario, Canada Njoyn Full time
Reporting to the Clinical Manager, the Care Coordinator, in collaboration with the patient, physician, caregiver, family, and care-team members, identifies appropriate patients for the bundled care pilot "Southlake@Home". The care coordinator acts as the liaison between the home and community care providers and the Southlake hospital care team, including physicians. In the event that a patient's care needs change to an extent that Southlake@Home is not appropriate, the care coordinator identifies to the hospital care team and physicians that the patient will require a referral to CLHIN home and community care services.

The care coordinator will liaise with community providers on a daily basis and participate in joint problem solving. They will provide case management to ensure the provider interventions are meeting the patient's goals, refer to CLHIN home care in matters related to long-term care applications where required, and facilitate transitions to the CLHIN home and community care program as necessary. Knowledge of Quality Improvement methodologies, such as PDSA cycles, is an asset. Prior knowledge and experience working on the implementation of new care/clinical pathways and/or Best Practice Guidelines is also an asset. Data collection may be required. Providing information on community resources and facilitating referrals to Community Support Services is a requirement of this role.

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