Care Coordinator - Complex

Are you a registered nurse (RN, BScN) with experience and training specific to palliative care. Are you seeking a rewarding career that cares for others, in a professional practice that cares for you? You’re looking in the right place.

As a Complex Care Coordinator, you will coordinate the care and management of palliative care patients in the community across diverse and often complex settings. You will act as a patient advocate to affirm life, and offer supports that help patients live as actively as possible until death, with optimal quality of life.

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 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?

• In collaboration with patients and their families, assess care needs, determine eligibility for services, and develop individual care and service plans for the complex population
• Link patients with community service providers to maintain the patient’s safety in their own home while prioritizing the prevention of hospital admission or ED visits
• Coordinate and monitor care plan delivery
• Establish a helping relationship with patients and their families
• Act as a subject matter expert for colleagues and external partners with respect to palliative care needs of patients in the community.
• Balance patient needs and choices with available resources, ensuring patients’ values and preferences are respected

What must you have?

• Membership, in good standing, with an applicable regulatory body as a Registered Nurse (RN, BScN)
• 1+ years of recent experience in community health or a related field
• Training/certification specific to palliative care (i.e., Fundamentals, LEAP, CAPCE, etc.).
• Knowledge of:
  • EDITH protocol, Symptom Response Kits and DNR-C paperwork, and PPS Scale.
  • Common prognosis and trajectories of life-limiting conditions.
  • Pain and symptom management needs of palliative care patients
• Possesses a strong clinical background with a patient-centered approach
• Knowledge of the health care delivery system and community resources
• Is a natural motivator, leader and advocate
• 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 licence 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
• Competent with RAI assessment tools
• 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 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.