Clinical Care Coordinator

As a valued member of our Home and Community Care team, you will facilitate the journey through Ontario’s health care system by assessing referred patients, determining their health care needs and eligibility, and ensuring they receive the services and care they need, where and when they need them.

What will you do?

• Provide patient-centered care within an inter-professional team focus of supporting team-patient partnerships, promotion of health, and prevention of progression of disease
• Provide comprehensive clinical assessment and intervention for these patients to live well with chronic disease and in so doing prevents Emergency Department and hospital admissions.
• Provide care coordination for patients as they transition from hospital to home and as they remain in the community.
• Use evidence informed strategies to support the patient towards increased self-management and maintenance in their home setting
• Visit the patient where they are at within the Chatham Kent, region - which may include but not limited to the home, Hospital, and primary care offices and / or community resources agencies

• Conduct clinical nursing assessments based on patients’ level of need and discharge destination provides assessment, advice and recommendations to the appropriate receiving agency in order to assist patients.
• Complete appropriate assessments to support care coordination and service planning
• Develop a Coordinated Care Plan (CCP), lead the plan and collaborate with all team members. Acts to update the CCP regularly, develops an action plan for the patient in collaboration with the health care team.
• Complete a comprehensive medication reconciliation for each patient.
• Mobilize an “upstream” thinking through recognition of symptoms which serve as a foundation for care planning. Engage patient/caregivers in creating a holistic care plan inclusive of the dimensions of well-being that focuses on their goals and priorities
• Engage primary care, providers, and community partners as needed to create a coordinated care plan (CCP) based on patient priorities and goals. The plan can include traditional and cultural activities Share the care plan with patient/caregivers and partners
• Participate in Community of Practice (CoP) development for the sub region and to continue to contribute to CoP in the development of innovative practices
• Develops collaborative working relationships with community partners and enhances existing work relationships with a broad range of community agencies, to ensure that caregivers are linked seamlessly to community agencies that can support the patient who will transition from various acute and sub-acute environments to home care site.
• Collaborate with the patient/caregiver and care team, including primary care team, contracted service providers and community support agencies, to develop and deliver care plans that are patient centered, meeting the patient’s identified needs and goals, so that the patient’s need to access the emergency room and hospital is reduced
• Able to Navigate patients to multiple community resources with expert knowledge regarding available community resources in the sub region.
• Authorizes all services, medical supplies and equipment necessary to achieve the established program goal; obtains special authorization as required
• Provides for IHH (Intensive Hospital to Home) service planning as appropriate. Conducts transitional assessments, from hospital to provide seamless care
• Ensures the fiscally responsible use of appropriate resources to achieve the desired outcomes by mobilizing and integrating formal and informal patient support networks
• Participate in any primary care education and meetings to enhance the collaboration of the Clinical Care Coordinator into the multidisciplinary primary care team
• Collaborates with the management team as needed to collect data and reports as required
• Documentation in accordance to CNO standards
• Assesses and promotes a safe environment for patients, caregivers, family members, and staff.
• Adheres to policies and practices developed and implemented by Home and Community Care Support Services Erie St. Clair

What must you have?

• A Baccalaureate degree from a recognized university in the field of Nursing (and/or a combination of nursing education, training and experience) holding current registration with a regulated college in Ontario
• Minimum 2 years of relevant experience in a clinical setting as a Registered Nurse
• Sound knowledge of the Ontario health care system and working knowledge of community resources and roles of health care professionals
• Canadian Nurses Association (CNA) certification in an area of specialty in nursing is an asset
• Licensed with the College of Nurses of Ontario (CNO)
• Superior clinical assessment skills
• Solid knowledge of health care related legislation and practices
• Knowledge of direct care/case management models used in community health care Organizations to support system navigation and hospital avoidance
• Ability to work independently
• Effective interpersonal and communications skills
• Must have a valid driver’s license and access to a vehicle

• Ability to speak French or another second language

How do I apply?

By submitting an application, applicants are consenting to the sharing of their personal information with individuals from Home and Community Care Support Services Erie St. Clair who are participating in the selection process.

Home and Community Care Support Services Erie St. Clair is an equal opportunity employer. Individuals with a disability requiring accommodation during the application and/or the interview process should advise the recruitment contact so arrangements can be made.

As a condition of employment and in compliance with the Home and Community Care Support Services mandatory COVID-19 Vaccination Policy, all employees are required to be fully vaccinated against COVID-19. All staff are required to provide proof of vaccination with the following exceptions, in which case there would be a requirement to undergo regular COVID-19 rapid antigen screening tests:

• If there is a valid medical reason for not being fully vaccinated against COVID-19, documentation must be provided by a Medical Doctor or Nurse Practitioner and include the effective time-period for the medical reason
• If there is valid human rights grounds (e.g. religious beliefs), evidence must be provided in accordance with the Ontario Human Rights Code and deemed satisfactory to Home and Community Care Support Services

We thank all applicants for their interest, but advise that only those selected for an interview will be contacted.