Care Coordinator, Primary Care

**Primary Health Care Coordinator**

**Permanent Part-Time, 21 hours per week (0.60 FTE)**

Time for a change? Are you looking to work where your excellence will shine, professional standards are highly valued, and quality of care is respected? Do you want to practice in a setting where your voice helps shape how health care is provided, where you work in the community and in collaboration with other health care services in West Toronto? We are looking to expand our Primary Health Care team with the addition of a new Care Coordinator.

On December 15, 2021, Regeneration Community Services, Storefront Humber Inc., and The Four Villages Community Health Centre amalgamated to create the West Toronto Community Health Services (WTCHS), formally merging, and now integrating community mental health and addictions services, community support services, home care, and inter-professional primary health care services. Under one agency, our overarching goal is to provide the full range of coordinated community health and support services to help keep our clients physically and mentally healthy and living at home, in the community.

The mandate of the Primary Care division is to provide high quality, accessible primary health care to the communities within its West Toronto service area, in the context of the broader social and structural determinants of health. Primary care, clinical services and a wide range of health promotion programs are primarily aimed at seniors, families with young children, youth, and newcomers. Employees collaborate in an inter-professional team environment. The focus is on the client and capacity building. WTCHS has two locations in the west end of Toronto. It is funded by the Ontario Health - Toronto Region and is a member of the West Toronto Ontario Health Team.

We have a committed team of professionals - family doctors, nurse practitioners, registered nurses, chiropodists, physiotherapists, occupational therapist, dietitians, social workers, therapists, community health workers and administrative staff. As a valuable member of our inter-professional primary health care teams, the Primary Health Care Coordinator works closely and in collaboration with all primary care providers within Four Villages. We are seeking an experienced Registered Nurse to fulfil this role and as a key member of our inter-professional teams. This is a unionized position.

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This is an innovative role seeking to evolve the way in which Primary Health Care Services are provided in Ontario through streamlined and coordinated care with the Toronto Central LHIN. The Primary Health Care Coordinator actively collaborates with clients, caregivers, primary care, and allied providers within the organization and with external partners. This position will develop and execute _coordinated care plans _(CCP) based on client care goals to improve the care/supports for those clients with complex health needs to help maintain their well-being and independence in the community. The Primary Health Care Coordinator, with the assistance of Community Health Workers, mental health case managers and Toronto Central LHIN home and community care staff for wider system navigation, supports and coaches clients and their families/support persons in actively coordinating care within Four Villages as well as externally with other agencies. In addition, the Primary Health Care Coordinator creates formalized care teams consisting of multiple types of providers both internal and external to Four Villages. The Primary Health Care Coordinator also functions as a liaison between internal and external service providers, specialty medical clinics and the client and their family/support person.

The Primary Health Care Coordinator works within a framework that appreciates the impact of the social determinants on wellbeing and health as well as places an active emphasis on disease prevention and health promotion.

**KEY RESPONSIBILITIES**:

- Coordinate client care on an on-going basis:

- Develop comprehensive coordinated care plans (CCPs), taking a dynamic approach.
- Be the point of contact for clients with respect to any care coordination issues and health needs.
- Ensure implementation, evaluation, and revision of the CCPs, while monitoring care and progress towards goals and advise care team members of any new information as relevant to their role in the care for the client.
- Engage the formalized care team as required to manage care transitions or address changes in care status or client needs.
- Provide support and guide clients in making appropriate decisions to enable independence through various communication and coaching methods.
- Offer emotional support to clients and their families/support person.
- Works closely with care coordinators, case manager and mental health partners to ensure coordinated, quality, and timely care and follow-up.
- Performs physical assessments, treatment, triage, health education, and other clinical activities, f