Care Coordinator

**Job Description**:
Are you an experienced registered nurse, physiotherapist, occupational therapist, social worker, dietitian, 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.

As a **Care Coordinator,**you would be responsible for: assessing clients for eligibility, developing an overall service plan for clients, organizing and coordinating multi-disciplinary services, and ongoing monitoring and evaluation of an integrated caseload. The Care Coordinator interprets Ontario Health atHome services to clients and families, other professionals and community agencies. Rotation through any case management work assignment within Case Management Services may be required.

Whether you work in our office, in the community, or a health care facility - you will play a lead role in providing connected, accessible, patient-centered care - and be supported by our collaborative team that includes over 8,000 regulated health care and other professionals.

As a valued team member, your mission will be to help our patients be healthier at home, while you benefit from our supports for professional growth, personal wellness and work-life balance.

**What will you do?**
The Care Coordinator, Palliative Care is responsible for assessing clients for eligibility, developing an overall service plan for clients, organizing and coordinating multi-disciplinary services, and ongoing monitoring and evaluation of an integrated caseload. The Care Coordinator interprets Ontario Health atHome services to clients and families, other professionals and community agencies. Rotation through any case management work assignment within Case Management Services may be required.

**Primary Responsibilities**:

- Completes comprehensive patient assessments using a validated palliative assessment tool, including patient’s clinical, physical and psychosocial needs, and caregiver needs
- Assesses patient’s Palliative Performance Scale and eligibility for palliative and other services
- Assesses eligibility for hospice care and admission to palliative care units
- Develops an individualized care and service plan reflective of the patient’s identified priorities and desired outcomes; identifies strategies and resources to be used in attaining clinical outcomes
- Discusses plans for end-of-life care, goals of care and preferred place of death
- Coordinates and facilitates referrals and transfers to hospice and palliative care units
- Assists patients and caregivers in finding in-home palliative medical follow up and coverage
- Initiates and authorizes the implementation of the care plan through contracted providers, supplies and equipment necessary to achieve the care goals
- Maintains open communication with service providers, conducts case conferences and regular home visits to optimize care planning and appropriate services
- Partners with the Ontario Health atHome/Ottawa Hospital Medical Assistance in Dying (MAiD) Care Coordinator for those clients wanting and requiring assistance with MAiD.

**What must you have?**
- Registered Nurse (BScN or diploma) with a current Certificate of Registration from the College of Nurses of Ontario
- Degree in Nursing or other relevant health related field
- Case Management Certificate is an asset
- Minimum of one (1) year of experience in community health setting preferred
- Knowledge of community organizations and resources
- Effective interpersonal and communication skills
- Effective organizational and planning skills
- Basic proficiency with computerized information systems
- French language is an asset
- Must have a valid driver’s license and access to a vehicle
- Palliative care experience that includes advance care planning, goals of care and end of life care planning
- Professional experience in health care should include linkage with other community health agencies, needs assessment, care coordination and/or discharge planning
- 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?**

**Knowledge**:

- Knowledge of medical diagnoses and prognoses, symptom management, end-of-life care and cognitive/psychiatric disorders

**Skills and Abilities**:

- Effective planning, organizing, and evaluation skills to manage multiple patients, provide information reports, and take corrective action as required
- Ability to accurately complete required documentation, reports, forms, and recommendations
- Verbal and written communication skills to establish and maintain a wide range of partners (doctors, nurses, social workers, etc.) within the healthcare and Hospice community
- Ability to manages difficult conversations /situations such as advance care planning, goals of care, end-of-life and hospice care, and medical assistance in dying, in a healthy and effec