HISH Nurse Care Coordinator

7 days ago

Whitby, Canada Local Health Integration Networks Full time
Job Description

Are you an experienced registered nurse (RN) seeking a rewarding career that cares for others, in a professional practice that cares for you? You're looking in the right place.

Reporting to the Senior Manager/Manager, the High Intense Supports at Home (HISH) Nurse Care Coordinator is responsible for assessing patient eligibility for services/long term care placement, assessing patient care needs, and planning and authorizing service delivery to best meet the patient's needs. Care coordination activities will also include scheduling care conferences to conduct Coordinated Care Plans (CCP) and acting as a point of contact for contracted providers, patients and health system partners.

The HISH Nurse Care Coordinator will use their clinical knowledge to support specialized care delivery, participate in clinical rounds, obtain/monitor vital signs, and review and administer medications during home visits if immediate medical/clinical support is required.

What will you do?

- Conduct in-person case conferences with multi-system partners.
- Participate in comprehensive assessment and collaborative care plan development.
- Perform clinical assessments in the patient's home.
- Conduct assessments utilizing the interRAI Suite of Instruments relevant to Ontario Health atHome.
- Coordinate the delivery of quality, cost-effective, equitable and timely services.
- Perform comprehensive needs assessments for patients and their unique situations to determine eligibility of services using established criteria.
- Provide patient services in accordance with Ontario Health atHome policies, relevant legislation and professional disciplines.
- Act as primary contact for patients, communicating with patients, caregivers and contracted service providers regarding service plans.
- Participate in patient care reviews and reassessments.
- Take charge of facilitating every step of a patient's health care experience, providing them with the right information and helping them understand and manage their short and long-term health care goals.
- In collaboration with others, ensure all patient's needs are met and adjust the service plan based on changes in the patient's status.
- Maintain each patient's record that supports ongoing assessment and monitoring, and meets the relevant discipline and standards; document both written and electronically, in accordance with the College of Nurses and other standards to support the team.
- Counsel patients on the placement process utilizing established criteria and guidelines for patients seeking placement; obtain consent; complete functional, psychosocial, medical and financial documentation.
- Determine the patient's continuing eligibility for services and provide counseling and referral to other providers/agencies when service is decreased or discontinued, or when additional external agency support is required.
- Conduct reassessments for patients awaiting placement.
- Promote, educate and interpret the role and services of Ontario Health atHome to individuals, groups and community agencies, and health care partners.
- Maintain confidentiality and privacy by safeguarding patient information in accordance with legislation, professional college standards and Ontario Health atHome policy.
- Embody Ontario Health atHome mission, vision and values and apply quadruple aim (enhancing patient experience, enhancing provider/staff experience, improving value and improving population health) to support continuous quality improvement in daily work.
- Exemplify, embrace and intentionally promote an inclusive work environment where all are meant to feel they belong.
- Continually demonstrate a commitment to create a positive culture of equity, inclusion, diversity and anti-racism.

What must you have?

- University degree preferred in Nursing, or equivalent.
- Holds current appropriate unrestricted registration as a Registered Nurse from the College of Nurses of Ontario.
- Recent (preferably within the last 2 years) working experience conducting BP monitoring, physical and clinical assessments, medication management and administration, wound care, and blood glucose monitoring.
- Recent community experience and adequate knowledge of community resources.
- Minimum two (2) years coordination/case management/community health or related clinical experience.
- Experience working with diverse, multicultural groups (including homeless, acquired brain injury (ABI) and pediatrics).
- Knowledge of Ontario Health atHome's role in the community sector.
- Proficiency in prioritization in a quick and concise manner.
- Demonstrate excellent interpersonal, communication, and decision-making ability.
- Demonstrated computer literacy is required to facilitate the use of electronic patient records and assessments.
- Ability to work independently and co-operatively in busy multi-disciplinary situations.
- We have a mandatory COVID-19 vaccination policy. As a condition of employment, all employees are required to submit proof of COVID-19 vaccination status prior to start date.

What would give you the edge?

- Ability to speak French or another second language.

Hours of work:

All hours of operation (Initially Monday-Friday 0830-1630; 70 hours per bi-weekly pay period) subject to change as per the Collective Agreement.

Position location and travel:

Hybrid work model, subject to change.

Regular travel within the geographical region of Ontario Health atHome Central East may be required. A valid Ontario driver's license and access to a vehicle are necessary.

What do we offer?

We know wellness is supported with work-life balance. In an inclusive culture committed to support your passion for continuous learning, growth and innovation, we offer:

- Attractive comprehensive compensation packages and benefits.
- Valuable development opportunities.
- Membership in a world class defined benefit pension plan.
- Salary: $41.92-$51.91/hour.

Who we are:

We are Ontario Health atHome, ready to serve every person in Ontario. We partner with patients and caregivers, primary care providers, hospitals, long-term care and retirement homes, service providers and Ontario Health Teams, to deliver responsive, accessible, integrated, patient-centred care.

If you're interested in driving excellence in care and service delivery, and seeking an unparalleled opportunity to lead and learn, partner and connect, care and be cared for, this is your home.

Equity, Inclusion, Diversity and Anti-Racism Commitment:

Ontario Health atHome is committed to a culture of equity, inclusion, diversity and anti-racism. We are committed to attracting, engaging and developing a workforce that reflects the diverse communities we serve. We welcome and encourage applications from all qualified applicants. Accommodations for persons with disabilities required during the recruitment process are available upon request.

We thank all applicants for their interest; however, only those selected for an interview will be contacted.

Date Posted: March 12, 2025

Closing Date: March 19, 2025

Job Type: Full-time

Start Date: May 26, 2025

Program: Community

Branch: Whitby

Group: ONA

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