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Ontario Health atHome

Provincial coordinator of home and community care

Bilingual Care Coordinator

Medical, Clinical & VeterinaryConfirmed live in the last 24 hours
Full-timeOttawa, ON, CanadaCA$44.48 - CA$47.52

About the Job

Requirements

  • Registered Nurse with a Bachelor of Science in Nursing or diploma, registered with the College of Nurses of Ontario; or a degree or diploma in Physiotherapy and registration with the College of Physiotherapy of Ontario; or a degree or diploma in Occupational Therapy and registration with the College of Occupational Therapy of Ontario; or a degree in Social Work and registration with the Ontario College of Social Workers and Social Service Workers; or a degree in Speech Therapy and registration with the College of Audiologists and Speech-Language Pathologists of Ontario; or a degree in Foods and Nutrition or equivalent and registration with the College of Dietitians of Ontario.
  • Related professional experience, normally attained over a period of two years.
  • Fluency in English and French is required.
  • A valid driver’s license and access to a vehicle are required.
  • A Vulnerable Sector Check completed within the last six months is required.
  • Employees must submit proof of COVID-19 vaccination status prior to their start date.

Responsibilities

  • Complete comprehensive patient assessments using a validated assessment tool, including clinical, physical, psychosocial, and caregiver needs.
  • Assess patients’ and caregivers’ understanding and learning needs related to diagnosis, treatment, available resources, illness adjustment, and coping mechanisms.
  • Assist patients and caregivers in setting appropriate individual or joint, short- or long-term goals.
  • Collaborate with patients, caregivers, and the care team to develop individualized care and service plans reflecting identified priorities and desired outcomes, and identify strategies and resources to attain clinical outcomes.
  • Coordinate the delivery of home and community care services to patients and caregivers.
  • Coordinate vendor and resource utilization involving medical equipment, supplies, and services.
  • Facilitate understanding and cooperation among members of the patient’s multidisciplinary healthcare team, and communicate with team members to maximize patient outcomes.
  • Initiate and authorize implementation of care plans through contracted providers.
  • Provide reports to physicians, service providers, patients, caregivers, and other authorized parties as required.
  • Document cases in accordance with Ontario Health atHome Champlain policies.
  • Manage a caseload of diverse patients with a range of health concerns; assess care needs through in-person visits and develop, implement, and update care plans informed by health and psychosocial needs, accommodating patient and caregiver wishes where possible.
  • Determine eligibility for and arrange Ontario Health atHome Champlain-approved health care services, and refer patients and caregivers to other community resources and programs.
  • Connect patients with care and services across their caseload geography, partnering with patients, families, caregivers, service providers, and community health providers supporting patients in their home environment.
  • Support Primary Care teams by strengthening relationships and improving communication and access to care for shared and new patients.

Desired Qualifications

  • Community-based professional experience is preferred.
  • Work with diverse patient groups with varying levels of comprehension and language capability.
  • Manage difficult conversations and situations, such as advance care planning and goals of care, in a healthy and effective manner.
  • Work effectively in a team environment and independently as required.
  • Use verbal and written communication skills to establish working relationships and maintain partnerships with doctors, nurses, social workers, and other healthcare-community partners.
  • Use listening and facilitation skills to work with patients and caregivers.
  • Use diplomacy when dealing with sensitive or confidential issues.
  • Build relationships to develop and maintain health and community stakeholder partnerships.
  • Have working knowledge of computer software, including email, internet, and Microsoft Office applications such as Word and Outlook.

About the Company

Ontario Health atHome

Provincial coordinator of home and community care

Ontario Health atHome coordinates in-home and community-based care for patients across Ontario and manages access to long-term care home placement. Its teams assess care needs, arrange services, and connect patients and caregivers with nursing, personal support, rehabilitation, and other community resources. The organization works with hospitals, primary care providers, Ontario Health Teams, and contracted service providers to plan care and support transitions between settings. It also helps people find health and social services, navigate supportive living options, and receive palliative care in their chosen setting. The agency was formed in June 2024 by amalgamating the fourteen Home and Community Care Support Services organizations.

Company size
5,001-10,000
Company stage
Not listed
Total funding
Not listed
Headquarters
Not listed
Founded
2024

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