Care Coordinator, Bilingual, Regular 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 and in accordance with the Home and Community Care Support Services Champlain standards, legislation, policies and guidelines, the Care Coordinator is responsible for client assessment, determination of eligibility, admission, service planning and authorization, implementation, monitoring, reassessment, adjustment and discharge planning of all client service programs (home care and placement), including the provision of community resource information and referral.
As a member of the Hospital Care Team, the Care Coordinator will work collaboratively with patients, families, caregivers, and hospital partners to develop a care plan to support a safe transfer from hospital to home for both complex and non-complex patients. Care Coordinators must prioritize work based on the ever changing needs of patients and hospital environment while meeting the Home and Community Care Support Services Champlain Guidelines of Care. The Care Coordinator will participate in various meetings to support care planning and communication with partners within the circle of care, including family meetings, care conferences, bullet rounds, and joint discharge rounds.

**Primary Responsibilities**:

- Identification and Engagement - Assesses referred clients for admission and establishes a helping relationship with eligible clients and their families while honoring the client’s values and preferences
- Assessment - Performs multi-dimensional assessment and identifies the need for crisis intervention and/or prevention strategies
- Goal Setting and Service Planning - Establishes a care and service plan balancing client’s needs, choices and available resources. Develops a care plan in collaboration with the client, other health care professionals, care providers or family, stating priorities, services authorized, mutual goals and anticipated duration of service
- Accessing Resources and Linking - Collaborates and partners with the networks of service providers.
- Service Implementation - Initiates and authorizes the implementation of the care plan
- Accountability, Monitoring and Reassessment - Reviews and maintains care plan in compliance to quality standards, outcome measures, quality indicators
- Discharge Planning - Conducts discharges from service process and/or redirects clients and families to alternative resources

**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
- Degree in Speech Therapy and registered with the College of Audiologists and Speech-Language Pathologists of Ontario.
- Degree in Foods and Nutrition or equivalent and registered with College of Dietitians of Ontario
- All of the above require at least 2 years related professional experience

**Knowledge**:

- Knowledge of health care delivery system and community resources within the Champlain region
- Medical conditions and cognitive/psychiatric disorders
- Client centered, multi-disciplinary team approach to client care
- Proficient in the use of computerized processes including the use of mobile (laptop) technology

**Skills and Abilities**:

- Demonstrates effective time management and organizational skills
- Effective decision-making and problem-solving in crisis situations
- Ability to negotiate and implement an effective goal-oriented, client-centered care plan
- Team player with ability to accept and adapt to change
- Ability to maintain a positive attitude in stressful situations
- Ability to organize daily workload in the presence of frequent interruptions
- Fluency in English and French is required.
- Valid N95 Mask Fit Test results or documentation of a medical exception within the past two years
- Vulnerable Sector Check completed within the last six months

Affiliation: OPSEU

Pay Rate: Wages are in accordance with the collective agreement between Home and Community Care Support Services Champlain and OPSEU and starting salaries range from $40.409/hr. - $46.642/hr.

Shift: Monday to Friday, 8:30am to 4:30pm

Location: 1111 Ghisla