Care Coordinator (Rn)

Join the FLA OHT Home Care Modernization Team and play a key role in shaping the future of homecare across Ontario! We're looking for passionate care team members to fill a unique dual role that combines direct care with administrative responsibilities. If you're committed to delivering person-centered care, improving coordination, enhancing communication, embracing self-scheduling, and adapting care plans in real-time based on client needs and risks, we want you on our team. Our goal is to improve health outcomes for clients by ensuring they receive the right care, at the right time, in the right way. In this role, you'll not only provide hands-on care and coordinate support around your clients, but also take an active role in planning, advocating, and driving the overall care strategy.

JOB SUMMARY:

As a Health and Social Care Integrator, you will provide exemplary leadership to home and community care teams caring for clients who are at greatest risk of hospital admission, ED visits or long-term care admission, as well as their family and friend caregivers. HSCIs will manage relationships and collaborate with care coordinators specifically assigned to primary care patients and collaborate with primary care physicians and allied health professionals and a full range of community support agencies and programs. Additionally, this position be involved in quality improvement initiatives to ensure key performance targets are met.

RESPONSIBILITIES:

• Manage health human resource utilization and skill mix to enable clients to live and age well at home.
• Address adverse events, conduct risk investigations, and develop risk management strategies following established policies and procedures.
• Upon client's referral and in collaboration with clients and caregivers, prepare initial care plans addressing clients' most immediate concerns and needs, and, when interRAI HC assessments are available, contribute to the development of Coordinated Care Plans for clients and caregivers, with their collaboration.
• Advocate for and organize access to necessary care, supports and services for clients and caregivers to enable them to live and age well at home.
• Review and interpret InterRAI HC assessments and the resulting care plans to ensure holistic client goals and needs are being met, including reductions in the risk of hospital admission, ED visits and long-term care admission
• Manage client and caregiver tracking tools and monitor and communicate significant care plan deviations or risk events.
• Lead, coach and support interdisciplinary teams to ensure safe, effective and efficient care for clients and caregivers in collaboration with care coordinators, community support agencies and programs, primary care physicians and allied health professionals.
• As part of the interdisciplinary care teams, provide in-home care for clients and caregivers to maintain consistent contact with clients and caregivers; finetune the day-to-day, week-to-week, month-to-month care and supports by a broad team of in-home home care providers and community support services; and provide relevant information to primary care providers and allied health professionals about their patients
• Provide on-call support and act as the main contact for care integration and communication with clients and families.

REQUIREMENTS:

• Registered Nurse in good standing with the College of Nurses of Ontario.
• Minimum of 5 years of clinical experience.
• Completed or in-progress oncology certification from a recognized educational institute such as DeSouza Institute.
• Completed or in-progress at least one of the following palliative certifications: LEAP, Fundamentals or CAPCE.
• Clinical expertise in home and community care, with preferred experience in Oncology, Palliative Care, and Wound Care.
• Knowledge of health and social care systems, including primary care, hospital discharge planning processes and community support services.
• Technologically savvy, with proficiency in Microsoft Office and collaboration tools.
• Adaptable to fast-paced environments and able to work on-call after hours.
• Must have a vehicle, a valid driver's license, and the ability to travel.

About SE Health

At SE, we love what we do. Every day, we bring hope and happiness to clients, homes, and communities across Canada. We treat each person with dignity and love, like our own family; we build empathy; and we do the right thing. We are always inspired to make a difference. As a not-for-profit social enterprise, we share knowledge, provide the best care, and help each client to realize their most meaningful goals for health and wellbeing. We are an inclusive workplace offering competitive pay, benefits, pension, and work life balance. We're a great place to work, and we hope you'll join our team.

In the interest of the health and safety of our patients/clients, employees, and greater good of public health, SE Health requires those that wish to work for this organization to be fully vaccinated against COVID-19. Fully vaccinated means a person has received both doses of the COVID-19 vaccine and it has been 14 days since the last dose.

SE Health is committed to the success of all its employees. If you feel you need accommodations because of illness or disability, please do not hesitate to contact the Talent Acquisition team at careers@sehc.com at your earliest convenience.