Care Coordinator

Ontario Health atHome; Ottawa; On-site; CAD 72,000 - 88,000; Full time

Benefits offered by this job

Competitive compensation

Generous benefits

Job summary

Ontario Health atHome in Ottawa is seeking a registered nurse to join our Palliative Care team as a Bilingual Care Coordinator. You will assess patient needs, determine eligibility, arrange access to community services, and collaborate with patients, caregivers and health professionals to support home-based care.

In this 35-hour week, Monday to Friday, you will conduct home visits or calls, develop care plans, coordinate referrals to hospice and MAiD partnerships, and help families navigate the

Qualifications

• Registered Nurse with current Certificate of Registration from the College of Nurses of Ontario.
• Two years of related professional nursing experience with palliative care focus including advance care planning and end-of-life care.
• Experience coordinating with community health agencies and discharge planning; MAiD experience is an asset.

Responsibilities

• Complete comprehensive patient assessments using a validated tool; assess Palliative Performance and eligibility for services.
• Develop individualized care and service plans aligned with patient and caregiver goals.
• Coordinate referrals to hospice and palliative care units; facilitate transfers and home follow-up.
• Assist patients and caregivers in navigating the health care system and accessing community resources.
• Communicate with a wide range of care providers to optimize care planning.

Skills

Bilingual English/French

Verbal and written communication

Planning and organizing

Documentation

Education

RN with BScN or diploma

Certificate of Registration from College of Nurses of Ontario

Job description

Are you an experienced registered nurse 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, Palliative Care 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?

The Bilingual Care Coordinator, Palliative Care is responsible for, or supports other Care Coordinators in managing, a caseload of palliative patients who are at different stages of illness trajectories and may require a palliative approach to care. The Care Coordinator, through home visits and/or phone conversations, measures the patient’s and caregiver’s care needs and develops, implements, and updates (as required) a care plan that is informed by the patient’s and caregiver’s wishes and preferences. He/she assists the patient and caregiver in navigating the health care system and also determines eligibility and refers to other community resources and programs, such as Hospice care and the Regional Palliative Consultation Team.

Primary Responsibilities:

• Completes comprehensive patient assessments using a validated assessment tool, including patient’s clinical, physical and psychosocial needs, and caregiver needs
• Assesses patient’s Palliative Performance Scale and eligibility for palliative and other services
• Assesses eligibility for hospice care and admission to palliative care units
• Develops 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
• Discusses plans for end-of-life care, goals of care and preferred place of death
• Coordinates and facilitates referrals and transfers to hospice and palliative care units
• Assists patients and caregivers in finding in-home palliative medical follow up and coverage
• Initiates and authorizes the implementation of the care plan through contracted providers, supplies and equipment necessary to achieve the care goals
• Maintains open communication with service providers, conducts case conferences and regular home visits to optimize care planning and appropriate services
• Partners with the Ontario Health atHome/Ottawa Hospital Medical Assistance in Dying (MAiD) Care Coordinator for those clients wanting and requiring assistance with MAiD.

Team/Department: Palliative

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

FTE: 1.0

Length of Temporary Assignment: to March 26, 2027

Affiliation: ONA

Reporting to: Manager, Patient Services

Office Location: Labelle

What must you have?

• Registered Nurse (BScN or diploma) with a current Certificate of Registration from the College of Nurses of Ontario
• Related professional nursing experience which is normally attained over a period of two years Palliative care experience that includes advance care planning, goals of care and end of life care planning
• Professional experience in health care should include linkage with other community health agencies, needs assessment, care coordination and/or discharge planning
• Canadian Nurses Association Certification in Hospice Palliative Care is an asset
• LEAP training is an asset
• Experience providing MAiD expertise are assets
• Fluency in both 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?

Knowledge:

• Knowledge of medical diagnoses and prognoses, symptom management, end-of-life care and cognitive/psychiatric disorders
• Knowledge of Champlain region Hospice and palliative care organizations and partners
• Knowledge of Hospice palliative care philosophy and approach
• Working knowledge of computer software (email, internet) and Microsoft Office applications (Word, Excel, Power Point, etc.)

Skills and Abilities:

• Effective planning, organizing, and evaluation skills to manage multiple patients, provide information reports, and take corrective action as required
• Ability to accurately complete required documentation, reports, forms, and recommendations
• Verbal and written communication skills to establish and maintain a wide range of partners (doctors,nurses, social workers, etc.) within the healthcare and Hospice community
• Ability to manages difficult conversations /situations such as advance care planning, goals of care, end-of-life and hospice care, and medical assistance in dying, in a healthy and effective manner
• 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.