CARE AND BE CARED FOR – THIS IS YOUR HOME

Are you an experienced registered nurse (BScN) , seeking a rewarding career that cares for others, in a professional practice that cares for you? You’re looking in the right place.

Ontario Health atHome Mississauga Halton is seeking two Registered Nurses (RN)to join the Mississauga Ontario Health Team, leading a Project on a Temporary Full-Time basis.

The Care Coordinator, Mississauga Ontario Health Team (M OHT) is responsible for collaborating with patients and their families/caregivers to develop quality, timely and cost-effective individual plans for service provision, based on patient needs, utilizing a multi-disciplinary approach to achieve optimal health outcomes. In supporting the development of a robust coordinated care plan, the Care Coordinator (CC) may connect the patients to additional resources and supports in the broader system.

The purpose of this position is to assist patients in safely achieving their highest level of functioning and independence, consistent with their values, priorities, capacities and preferences for care. Care Coordinators will collaborate with patients, hospitals, primary care providers, service provider organizations, and community support service organizations to plan and deliver care and ensure patients are connected to other supports. In accordance with the Connecting Care Act, 2019 and its regulations, the Care Coordinator assesses patient needs, determines eligibility for services, plans and implements care, helps coordinate service delivery with an inter-disciplinary team, and reviews patients’ care plans as required to ensure needs are being met to achieve their goals of care. Care Coordinators will also carry out their duties in accordance with Ontario Health atHome policies and the Leading Project (LP) OHT’s policies, procedures and parameters relating to the delivery of Care Coordination functions, including mandatory points of consultation, communication and collaboration with the other members of the integrated care team.

Care Coordinators report to an Ontario Health atHome (OHaH) Patient Services Manager for employment-related matters and are accountable to the Leading Project OHT for advancing integrated, team-based care.

With shared accountability between OHaH and the OHT, and with clearly defined models of home care planning, policies, service allocation and delivery informing accountability, roles and responsibilities, Care Coordinators connected with an Ontario Health Team Leading.

Project will work as part of an integrated care team with OHT partners to carry out care coordination functions. As an integral member of the integrated care team, the Care Coordinator will contribute to the testing of home care models that improve integration, access, and patient outcomes and experience. Leveraging the key activities of care coordination, the OHT LP CC will help to inform potential scale and spread of new models of home care, including system processes and supports. Through the LP, the CC will contribute to building OHT and health system capacity for home care planning, delivery, and integration.

Mississauga OHT Leading Project Details:

In addition to Care Coordination duties outlined in the Care Coordinator job description, the role may include, but not be limited to the following:

• Assess the health status of the patient, including but not limited to ESAS and PPS
• Initiate Goals of Care discussions and End of Life planning
• Educate on “What to expect with regards to Palliative Care and EOL” including palliative resources available
• Provide Pain and Symptom Management by being familiar with contents of Symptom Management Kit and other prescribed medications
• Administer other medications as prescribed via the prescribed route
• Educate patient and family re: use of narcotic medication and other medications
• Initiate and monitor the CAAD PCA Pump
• Complete a medication reconciliation (MedRec)
• Administer IV hydration as per medical orders including IV start if required
• Educate and support patients and families with new IV/injectable medications and assess ongoing needs.
• Complete Do Not Resuscitate (DNR) and Expected Death In The Home (EDITH) form as appropriate
• Provide emotional and psycho-social support to the patient and family/caregivers
• Consult with MRP and Palliative care Nurse Practitioner as required
• Empty and maintain care of drains and catheters (e.g. PleurX, Tenckhoff, etc.), as applicable
• Provide patient care as per the patient’s care plan.
• Provide support to patient/family for Medical Assistance in Dying (MAID) provision as required
• Report any changes in health status to the MRP and Ontario Health atHome Palliative Care Coordinator
• Perform any additional tasks that may be asked of you to perform that are within the CNO (RN) scope of practice guidelines according to your skills, knowledge and judgement to perform.

What will you do?

Care Coordinators will be responsible for:

• Assessing - and reassessing when appropriate - patient requirements, including through mandatory interRAI assessments, but not including additional clinical assessments and other interRAI assessments;
• Making determinations of eligibility.
• Developing care plans, and evaluating and revising them as necessary when the patient’s requirements change;
• Terminating the provision of a service.

Care coordinators will also be responsible for working with staff of HSPs and SPOs, who may also be responsible for:

• Revising care plans (i.e. – number of visits, types of services) based on clinical expertise, within the context of the approved model of care, and in accordance with written arrangements between the Leading Project HSP and the HSP or SPO performing these care coordination functions;
• Carrying out additional clinical assessments to inform care planning, including by the Ontario Health atHome Care Coordinator;
• Assessing/reassessing patient needs for other health and social services offered by the Leading Project HSP, such as mental health and addictions, housing, community supports, etc.;
• Providing information about - and referrals to - providers of other health and social services.

Care coordinator responsibilities will also include:

• Identification and Engagement
• Patient Needs Assessments
• Accessing Resources and Linking
• Clinical Care
• Community Relations
• Care Planning and Coordination
• Monitoring and Reassessment
• Resource Management and Fiscal Accountability
• Evaluation
• Documentation

What must you have?

• A member in good standing with College of Nurses of Ontario (Registered Nurse)
• A University degree is preferred. An equivalent combination of education and experience may be considered.
• Minimum two years recent experience in community health or a related field (acute, hospice, home and community care settings).
• Palliative experience preferred.
• Community nursing experience is an asset.
• Sound knowledge of the Ontario health care system, the role of Care Coordinator as assessor and health planner, all relevant legislation and available local community resources
• Basic knowledge of and adherence to relevant legislation and regulations, including the Home and Community Care Services Regulation of the Connecting Care Act, 2019 and Personal Health Information Protection Act (PHIPA);
• Basic understanding of issues and priorities within the healthcare sector;
• Good knowledge of Home Care patient services strategies, objective, priorities
• Knowledge of direct care/case management models used in community health care organizations to support system navigation and hospital avoidance.
• Excellent interpersonal, communication, assessment, problem-solving and decision-making skills
• Effective time management, prioritization and organizational skills, with the ability to work independently and co-operatively in a busy multidisciplinary environment
• Established ability to accurately complete required documentation, reports and forms
• A valid driver’s license and access to a reliable vehicle
• Proficient in a Windows environment
• 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?

• Experience working with diverse patient groups, e.g., multicultural, homeless, palliative, acquired brain injury (ABI), mental health, geriatrics, pediatrics
• Case management experience or recent related community experience
• Ability to speak French or another second language

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 Range (CUPE) - $43.55 to $50.67

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-centred care.

Why join us?

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.

We thank all applicants for their interest; however, only those selected for an interview will be contacted.