Care Coordinator

Position Summary:

Under the general direction of the Manager, Home and Community Care, the Care Coordinator is responsible for managing a caseload of diverse patients who are living and/or dealing with a variety of health concerns. The Care Coordinator, through in person visits, assesses the patient’s care needs and develops, implements, and updates (as required) a care plan that is informed by the patient’s health and psychosocial needs; and, where possible, accommodates patient and caregiver wishes. He/she also determines eligibility for and arranges for HCCSS Champlain-approved health care services and refers patients and caregivers to other community resources and programs.

As a member of the Community Care Team, the Care Coordinator will provide a broad scope of connection in their caseload geography, linking with care and services beyond community care while partnering closely with patients, families, caregivers, service providers and other community health providers supporting the patient in their home environment.

The Care Coordinator may also provide support to Primary Care teams strengthening the relationship and improving communication and access to care for shared patients as well as new patients.

Primary Responsibilities:

• Completes comprehensive patient assessments using a validated assessment tool, including patient’s clinical, physical and psychosocial needs, and caregiver needs
• Assesses the patient’s and caregiver’s understanding of, and learning needs related to diagnosis, treatment, available resources, illness adjustment, and coping mechanisms
• Assists patient and caregiver in setting appropriate goals (individual, joint, short or long term)
• Collaborates with patient, caregiver and the care team to develop 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
• Coordinates the delivery of Home and community care services to patients and their caregivers
• Coordinates vendor and resource utilization involving medical equipment, supplies and services
• Facilitates understanding and cooperation among members of the patient’s multidisciplinary healthcare team; communicates with members of the patient’s health care team to maximize patient outcomes
• Initiates and authorizes the implementation of the care plan through contracted providers
• Provides regular reports to Physicians, service providers, patients, caregivers and other authorized parties as required
• Case documentation in accordance with Home and Community Care Support Services Champlain policies

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; or
• Degree in Speech Therapy and registered with the College of Audiologists and Speech-Language Pathologists of Ontario; or
• Degree in Foods and Nutrition or equivalent and registered with College of Dietitians of Ontario.
• Related professional experience (community based experience preferred) which is normally attained over a period of two years

Knowledge:

• Knowledge of medical diagnoses and prognoses, symptom management, and cognitive/psychiatric disorders
• Knowledge of case management principles and best practices
• Knowledgeable about resource availability, service costs, budgetary parameters
• Knowledge of relevant health care legislation

Skills and Abilities:

• Works with diverse patient groups with varying levels of comprehension and language capability
• Manages difficult conversations/situations such as advance care planning and goals of care in a healthy and effective manner
• Works effectively in both a team environment and independently as required
• Verbal and written communication skills to establish working relationships and maintain a wide range of partners (doctors, nurses, social workers, etc.) within the healthcare community
• Listening and facilitation skills to work with patients and their caregivers
• Diplomacy in dealing with sensitive and/or confidential issues
• Relationship building skills to develop and maintain health and community stakeholder partnerships.
• Working knowledge of computer software (email, internet) and Microsoft Office applications (Word, Outlook, etc.)
• A valid driver’s license and access to a vehicle is required
• 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. - $43.169/hr.
Shift: Monday to Friday, 8:30am to 4:30pm
Location: 1100 Pembroke st East, Pembroke

Assignment: Working with the homeless population

This position is temporary until approximately April 2025

Please note that selection will be in accordance with Article 12.02 of the Collective Agreement (Selection).

Home and Community Care Support Services Champlain offers flexible work options, this position will have a hybrid model of work with a combination of work locations, including community and clinical settings, patients’ homes, on-site, and remote.

All applications will be reviewed; however, only those selected for an interview will be contacted. Home and Community Care Support Services Champlain welcomes and encourages applications from people with disabilities. Accommodations are available on request for candidates taking part in any aspects of the selection process.

Home and Community Care Support Services has implemented a mandatory vaccination policy across the province that requires all staff to be fully vaccinated against COVID-19. Applicants being considered for employment will be required to provide proof of vaccination documentation confidentially to Human Resources upon hire. Any medical or human rights exemption requests will be reviewed and validated prior to an offer of employment.