Care Coordinator

Ontario Health atHome; Ottawa; On-site; CAD 65,000 - 90,000; Full time

Benefits offered by this job

Attractive compensation packages

Defined benefit pension plan

Job summary

Ontario Health atHome is seeking a Bilingual Care Coordinator to assess patient needs, determine eligibility, and connect clients with community resources. This role supports patients at home across Champlain with a collaborative care team.

The Care Coordinator will manage diverse caseloads, develop care plans, liaise with physicians and caregivers, and ensure timely access to services and supports within the home setting.

Qualifications

• Registered professional in their respective field with active license.
• Two years of related community-based experience preferred.
• Fluency in English and French required.

Responsibilities

• Assess patient care needs and develop individualized care plans.
• Determine eligibility for Ontario Health atHome Champlain services.
• Coordinate home and community care services and vendor resources.
• Document case notes and provide regular reports to the care team.
• Engage with patients, families and caregivers to support outcomes.

Skills

English & French fluency

Education

Registered Nurse (BScN or diploma) - Ontario

Physiotherapist - Ontario College

Occupational Therapist - Ontario College

Social Worker - Ontario College of Social Workers

Dietitian - College of Dietitians of Ontario

Speech-Language Pathologist - Ontario College

Job description

Are you an experienced registered nurse, physiotherapist, occupational therapist, social worker (RSW), dietitian, or speech language pathologist 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 Bilingual Care Coordinator, you will assess and determine patient care needs and eligibility, provide access and referrals to community services, and engage with patients, caregivers and other health care practitioners.

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-centred 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?

Under the general direction of the Manager, Patient Services, 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, 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 Ontario Health atHome 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 Ontario Health atHome Champlain policies

Hours of work: 8:30am-4:30pm – Monday to Friday (35hrs/week)

FTE: 1.0

Length of Temporary Assignment: May 14, 2027

Affiliation: ONA

Reporting to: Manager, Patient Services

Office Location: Labelle

What must you have?

• 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
• Fluency in English and French is required.
• 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?

• 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

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
• Membership in a world class defined benefit pension plan

Who are we?

We are Ontario Health atHome, ready to serve every person in Ontario. We partner with patients and caregivers, family physicians, 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.

This job posting is for an existing vacancy.