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Ontario Health atHome

Provincial coordinator of home and community care

Bilingual Care Coordinator - Congregate Care Team East

Medical, Clinical & VeterinaryConfirmed live in the last 24 hours
ContractOttawa, ON, CanadaCA$44.48 - CA$47.52 /hr

About the Job

Requirements

  • Registered Nurse with a Bachelor of Science in Nursing or diploma and registration with the College of Nurses of Ontario, or a degree or diploma in Physiotherapy and registration with the College of Physiotherapy of Ontario.
  • A degree or diploma in Occupational Therapy and registration with the College of Occupational Therapy of Ontario.
  • A degree in Social Work and registration with the Ontario College of Social Workers and Social Service Workers.
  • A degree in Speech Therapy and registration with the College of Audiologists and Speech-Language Pathologists of Ontario.
  • 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; community-based experience is preferred.
  • Proof of COVID-19 vaccination status is required before the start date.
  • 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.

Responsibilities

  • Complete comprehensive patient assessments using a validated assessment tool, including the patient's clinical, physical, and psychosocial needs and caregiver needs.
  • Assess the patient’s and caregiver’s understanding of, and learning needs related to, diagnosis, treatment, available resources, illness adjustment, and coping mechanisms.
  • Assist patients and caregivers in setting appropriate individual, joint, short-term, or long-term goals.
  • Collaborate with patients, caregivers, and the care team to develop an individualized care and service plan reflecting the patient's priorities and desired outcomes, and identify strategies and resources to achieve clinical outcomes.
  • Coordinate 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 the care plan through contracted providers.
  • Provide regular reports to physicians, service providers, patients, caregivers, and other authorized parties as required.
  • Document cases in accordance with Ontario Health atHome Champlain policies.
  • Act as a single point of contact to improve collaboration and communication in congregate settings, including retirement homes.
  • Through home visits and phone conversations, assess patient care needs and develop, implement, and update care plans informed by health and psychosocial needs and, where possible, patient and caregiver wishes.
  • Determine eligibility for Ontario Health atHome-approved health care services, arrange those services, and refer patients and caregivers to other community resources and programs.
  • Participate in and provide guidance at meetings with stakeholders involved at each site, and foster direct engagement with patients and their care partners.

Desired Qualifications

  • Community-based professional experience is preferred.
  • Knowledge of medical diagnoses and prognoses, symptom management, and cognitive or psychiatric disorders.
  • Knowledge of case management principles and best practices.
  • Knowledge of resource availability, service costs, and budgetary parameters.
  • Knowledge of relevant health care legislation.
  • Knowledge of care delivery in congregate settings.
  • Ability to work with diverse patient groups with varying levels of comprehension and language capability.
  • Ability to manage difficult conversations and situations, such as advance care planning and goals of care, in a healthy and effective manner.
  • Ability to work effectively in a team environment and independently as required.
  • Verbal and written communication skills to establish working relationships and maintain partnerships with doctors, nurses, social workers, and other healthcare community members.
  • Listening and facilitation skills for working with patients and caregivers.
  • Diplomacy in dealing with sensitive or confidential issues.
  • Relationship-building skills to develop and maintain health and community stakeholder partnerships.
  • Working knowledge of email, internet, and Microsoft Office applications, including 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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