Care Coordinator
Local Health Integration Networks
Ottawa
1d ago

Position Summary

Under the general direction of the Manager, Home and Community Care, the Care Coordinator is responsible for managing a caseload of diverse patients who are living and / or dealing with a variety of health concerns.

  • The Care Coordinator, through in person visits and / or phone conversations, assesses the patient’s care needs and develops, implements, and updates (as required) a care plan that is informed by the patient’s health and psychosocial needs;
  • and, where possible, accommodates patient and caregiver wishes. He / she also determines eligibility for and arranges for HCCSS Champlain-approved health care services and refers patients and caregivers to other community resources and programs.

    As a member of the Community Care Team, the Care Coordinator will provide a broad scope of connection in their caseload geography, linking with care and services beyond community care while partnering closely with patients, families, caregivers, service providers and other community health providers supporting the patient in their home environment.

    The Care Coordinator may also provide support to Primary Care teams strengthening the relationship and improving communication and access to care for shared patients as well as new patients.

    Primary Responsibilities :

  • Completes comprehensive patient assessments using a validated assessment tool, including patient’s clinical, physical and psychosocial needs, and caregiver needs
  • Assesses the patient’s and caregiver’s understanding of, and learning needs related to diagnosis, treatment, available resources, illness adjustment, and coping mechanisms
  • Assists patient and caregiver in setting appropriate goals (individual, joint, short or long term)
  • Collaborates with patient, caregiver and the care team to develop an individualized care and service plan reflective of the patient’s identified priorities and desired outcomes;
  • identifies strategies and resources to be used in attaining clinical outcomes

  • Coordinates the delivery of Home and community care services to patients and their caregivers
  • Coordinates vendor and resource utilization involving medical equipment, supplies and services
  • Facilitates understanding and cooperation among members of the patient’s multidisciplinary healthcare team; communicates with members of the patient’s health care team to maximize patient outcomes
  • Initiates and authorizes the implementation of the care plan through contracted providers
  • Provides regular reports to Physicians, service providers, patients, caregivers and other authorized parties as required
  • Case documentation in accordance with Home and Community Care Support Services Champlain policies
  • Education and Experience :

  • Registered Nurse (BScN or diploma) and registered with the College of Nurses of Ontario; or
  • Degree or diploma in Physiotherapy and registered with the College of Physiotherapy of Ontario; or
  • Degree or diploma in Occupational Therapy and registered with the College of Occupational Therapy of Ontario; or
  • Degree in Social Work and registered with the Ontario College of Social Workers and Social Service Workers; or
  • Degree in Speech Therapy and registered with the College of Audiologists and Speech-Language Pathologists of Ontario; or
  • Degree in Foods and Nutrition or equivalent and registered with College of Dietitians of Ontario.
  • Related professional experience (community based experience preferred) which is normally attained over a period of two years
  • Knowledge :

  • Knowledge of medical diagnoses and prognoses, symptom management, and cognitive / psychiatric disorders
  • Knowledge of case management principles and best practices
  • Knowledgeable about resource availability, service costs, budgetary parameters
  • Knowledge of relevant health care legislation
  • Skills and Abilities :

  • Works with diverse patient groups with varying levels of comprehension and language capability
  • Manages difficult conversations / situations such as advance care planning and goals of care in a healthy and effective manner
  • Works effectively in both a team environment and independently as required
  • Verbal and written communication skills to establish working relationships and maintain a wide range of partners (doctors, nurses, social workers, etc.
  • within the healthcare community

  • Listening and facilitation skills to work with patients and their caregivers
  • Diplomacy in dealing with sensitive and / or confidential issues
  • Relationship building skills to develop and maintain health and community stakeholder partnerships.
  • Working knowledge of computer software (email, internet) and Microsoft Office applications (Word, Outlook, etc.)
  • A valid driver’s license and access to a vehicle is required
  • Vulnerable Sector Check completed within the last six months
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