Are you an experienced registered nurse (BScN), physiotherapist, occupational therapist, social worker, 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.
The Care Coordinator, Palliative Ontario Health Team (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 preference of 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 a 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:
Please note: Pending the go-live launch date of the Leading Project, the incumbent will work within the existing Palliative Care Coordination team model until the launch of the Leading Project
What will you do?
Care Coordinators will be responsible for:
Care coordinators will also be responsible for working with staff of HSPs and SPOs, who may also be responsible for:
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
Other Related Tasks:
Patient Safety:
What must you have?
Clinical Skills
Administrative and General Skills and Attributes
Communication & Interpersonal Skills
What would give you the edge?
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:
Who we are
We are Ontario Health atHome, ready to serve every person in Ontario. We partner with patients and caregivers, primary care providers, hospitals, long-term care and retirement homes, service providers and Ontario Health Teams, to deliver responsive, accessible, integrated, patient-centred 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.
We thank all applicants for their interest; however, only those selected for an interview will be contacted.