Primary Health Care Coordinator

Position: Permanent Part-Time - Primary Health Care Coordinator

Job ID: CCH-2509

Bargaining Status: C.U.P.E. Local 4891

Hours of Work: 21 hours per week, at least one evening per week is required.

Service Area: Primary Health Care

Reports To: Manager, Medical Services

**Salary**: $37,233 - $44,860 per annum (prorated for 0.60 FTE)

**About CommunitiCare Health**

We are a community health care agency that provides a full range of community health care and support services, making us a distinctive agency in Toronto offering a blend of community support services, community mental health and addictions services, supportive housing, inter-professional primary care and home care services. We are community governed. We continually look for ways to serve our clients and our community better and to provide enhanced access to equitable care.

**Key Responsibilities**

1. 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.

2. Performs physical assessments, treatment, triage, health education, and other clinical activities, for care coordination clients, according to the College of Nurses of Ontario standards and full scope of nursing practice.

3. Assist CCH's providers in identifying complex clients requiring CCPs.

4. Reach out, connect with and support CCH's clients experiencing high clinical health service utilization to better support them through inter-professional care (internal and external) via CCPs.

5. Ensure effective referral relationships across community agencies, social supports, and other service providers.

6. Facilitate positive relationship building and communication between clients, families, support person and their providers.

7. Provide education to the clients and training to Primary Health Care staff, as needed, to assist with navigating health care and social services.

8. Maintain complete and accurate client records and any other required documentation.

9. Incorporate and strengthen collaborative and interdisciplinary work.

10. Provide instruction, support and consultations regarding CCPs to staff, students, and volunteers.

11. Provide itinerant services working from different locations to create greater access to populations facing barriers to care.

12. Work during both regular and extended hours in locations identified by Communiticare Health (on-site and off-site).

13. Travel between sites and services and accompany clients to appointments as needed.

14. Respect and value the diversity of communities and individuals.

15. Contributes to programs and services cycle of planning and evaluation, and participates in center-wide planning, committees, and team meetings as appropriate.

16. Participates in inter-professional research with colleagues - internal and external to the Centre, as appropriate.

17. Maintains all licenses, certificates, and standards related to the ability to practice as an MD in Ontario.

18. Perform duties as assigned by the supervisor.

**Qualifications**
- Registered Nurse with appropriate regulatory college registration.
- Experience in Case Management/Care Coordination.
- Experience working with individuals facing multiple barriers, including individuals with complex health and/or mental health issues in a community setting.
- Experience working from a team-based model and within an inter-professional team.
- Strong assessment and clinical skills.
- Commitment to and knowledge of community health care and community outreach strategies.
- Open-minded, non-judgmental with a commitment to upholding the rights and dignity of all people and respecting their diversity.
- An ability to engage, motivate and coach clients to meet their goals.
- Training in therapeutic/counselling modalities, including CBT, mindfulness, relaxation, DBT, and coaching.
- Demonstrated ability to work within an inter-professional team environment and strong interpersonal skills.
- Excellent communication, decision-making, problem-solving, conflict management skills to effectively advocate on behalf of clients.
- Familiarity and understanding of Population Health and Equity in Health Care including an understanding of An