Care Coordinator Guelph Wellington Ontario Health Team Leading Project

November 14 2024
Industries Healthcare, social assistance
Categories Nursing, Population Health,
Guelph, ON • Full time

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

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-centred care - and be supported by our collaborative team that includes over 9,000 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?

The successful applicant will provide coverage for community and hospitals throughout Guelph Wellington until Leading Project is implemented.

Reporting to a OHaH Patient Services Manager for employment-related matters and accountable to the Leading Project OHT for advancing integrated, team-based care, the Care Coordinator 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; and
    • 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 OHaH 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
    • Community Relations
    • Care Planning and Coordination
    • Monitoring and Reassessment
    • Resource Management and Fiscal Accountability
    • Evaluation
    • Documentation
    • Patient Safety

Other Related Tasks:

    • Work respectfully, positively and collaboratively within a team environment, sharing experiences and lessons learned;
    • Collaborate with team members regarding coverage for patient care;
    • Embody OHaH mission, vision and values and apply quintuple aim (enhancing patient experience, enhancing provider/staff experience, improving value, improving populations health, and advancing health equity) to support continuous quality improvement in daily work;
    • Embody mission, vision, and values of the OHT;
    • Exemplify, embrace and intentionally promote an inclusive work environment where all are meant to feel they belong;
    • Continually demonstrate a commitment to create a positive culture of equity, inclusion, diversity and anti-racism;
    • Implement new procedures and controls deemed necessary by management;
    • Assist in the training, orientation, precepting and mentoring of peers. Acts as a resource to other LP OHT staff and members of the integrated team to assist in orientation, implementing change, and problem solving;
    • Assist with projects and new initiatives as they relate to position;
    • Participate on committees;
    • Promote Best Practice and helps define best practices;
    • Promote and supports research initiatives related to the Leading Project;
    • Participate in relevant educational opportunities;
    • Travel throughout the OHaH geography as required;
    • Other duties as assigned.

What must you have?

    • Knowledge and application of case management principles and practices acquired through membership in good standing, with the appropriate college, as a Registered Nurse, Occupational Therapist, Physiotherapist or Speech Language Pathologist, Registered Dietician, or membership in good standing with the College of Social Work, with a degree at the Master's level, preferred.
    • Appropriate university degree or a suitable combination of education and direct experience
    • Field of registration must allow applicant to determine patient capacity in accordance with the Health Care Consent Act (1996)
    • 1-3 years of experience in community health or a related field
    • Minimum 2-3 years of relevant recent experience in case management is an asset
    • Community nursing experience is an asset
    • Strong written and verbal communication skills
    • Proven skills in the areas of case management, assessment, communication, interviewing, problem solving, interpersonal and leadership within a team based setting is required
    • The ability to work independently in a highly organized manner is required
    • This position also requires proficiency in the use of a personal computer in a windows networked environment, using Word and database software
    • The ability to travel throughout Waterloo Region and Wellington County is required
    • Fluency in French language preferred.

This position will be assigned Guelph IPCTs. This position may be required to provide relief at other Ontario Health atHome locations or teams as needed and may be part of the on call rotation as per the provisions of the ONA collective agreement.

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​
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.

If you are interested in this position, please submit a cover letter, along with a detailed resume, outlining how your skills, qualifications and experience meet the position requirements, quoting Competition 24-O-112 CC TFT OHT LP (12m) before 4:30 pm on Thursday, November 21, 2024 to HR.WW@ontariohealthathome.ca .

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

Apply now!

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