Job Description:

Are you an experienced registered nurse, physiotherapist, occupational therapist, social worker, dietitian, or speech language pathologist seeking a rewarding careers that cares for others, in a professional practics that cares for you? You're in the right place.

As a Hospital Care Coordinator, you will assess and determine patient care needs and eligibility, provide access and referrals to community services, and engage with patients, caregivers and other health care practitioners.

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?
Under the general direction of the Manager, Patient services and in accordance with the Ontario Health atHome 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 Ontario Health atHome 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:

• 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 Ontario Health atHome Champlain policies

Team/Department: Western Champlain

Hours of work: Monday - Friday, 8:30AM - 4:30PM
FTE: 1.0

Starting Salary: $44.480 to $47.517

Affiliation: OPSEU

Reporting to: Manager, Patient Services

Office Location: Pembroke Regional Hospital

What must you have?

• 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

What would give you the edge?

• 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
• Fluency in English and French is an asset.
• Vulnerable Sector Check completed within the last six months

Hours of Work

Hours of work: Monday - Friday, 8:30AM - 4:30PM

We offer flexible work options, this position will have a hybrid model of work with a combination of in-office and telework.

What do we offer?

We know wellness is supported with work-life balance. In an inclusive culture committed to support your passion for continuous learning, growth and innovation, we offer:

• Attractive comprehensive compensation packages and benefits
• Valuable development opportunities
• Membership in a world class defined benefit pension plan
• Salary: $44.480 to $47.517

Who are we?

We are Ontario Health atHome, ready to serve every person in Ontario. We partner with patients and caregivers, family physicians, hospitals, long-term care and retirement homes, service providers and Ontario Health Teams, to deliver responsive, accessible, integrated, patient-centered care.

If you’re interested in driving excellence in care and service delivery, and seeking an unparalleled opportunity to lead and learn, partner and connect, care and be cared for, this is your home.

Equity, Inclusion, Diversity and Anti-Racism Commitment

Ontario Health atHome is committed to a culture of equity, inclusion, diversity and anti-racism. We are committed to attracting, engaging and developing a workforce that reflects the diverse communities we serve. We welcome and encourage applications from all qualified applicants. Accommodations for persons with disabilities required during the recruitment process are available upon request.

All applications will be reviewed; however, only those selected for an interview will be contacted. Ontario Health atHome 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.

Ontario Health atHome 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.