Clinical Care Coordinator
4 weeks ago
Job Summary
North York General Hospital (NYGH) is seeking a skilled Clinical Care Coordinator to join our team. As a key member of our Transitional Care Program, you will play a vital role in providing clinical support, patient and family education, and comprehensive care facilitation for NYG@home and the NYCARES integrated care initiative.
Key Responsibilities
- Onboard eligible patients and caregivers, providing education and engagement
- Support patient navigation through care pathways, assessments, planning, implementation, evaluation, and documentation
- Coordinate with hospital and community staff to facilitate discharge planning meetings and follow up with primary care providers, hospital physicians, and specialists as needed
- Ensure timely patient access to appointments, tests, and follow-up care
- Use clinical expertise to direct or modify care pathways to meet patient needs
- Facilitate advance care planning with the most appropriate provider
- Lead and facilitate inter-professional patient care rounds and case conferences as needed
- Be the primary contact for patients, families, and care providers in the hospital and community
- Enable the flow of information in adherence with privacy legislation
- Facilitate seamless transitions across the care continuum
- Contribute to the hospital's and Ontario Health Team's mission, vision, values, and strategic direction
Requirements
- Regulated healthcare professional required
- Current registration, in good standing with the applicable college required
- Minimum three years' community care experience
- Demonstrated expertise in the management and care coordination for seniors, patients with complex care needs, chronic diseases, mental health, and addictions, and/or palliative care
- Experience providing patient education
- Strong commitment to Patient and Family Centered Care
- Expert clinical skills in the assessment, planning, implementing, evaluating, and documenting of the delivery and coordination of care for patients and their families living with chronic disease and/or elderly patients with medical needs
- Strong leadership, critical thinking, decision making, problem recognition, and solving skills
- Solid understanding of community services and supports
- Current experience working collaboratively with and leading a multi-disciplinary team
- Excellent communication and interpersonal skills
- Experience in evaluation and quality improvement
- Experience with project implementation and evaluation preferred
- Experience working with seniors in a clinical or community setting preferred
- Bilingualism in French/English an asset
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