Care Coordinator - Palliative Ontario Health Team (OHT)

Job Description

Are you an experienced registered nurse (BScN), physiotherapist, occupational therapist, social worker, 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.

The Care Coordinator, Palliative Ontario Health Team (OHT) is responsible for collaborating with patients and their families/caregivers to develop quality, timely and cost-effective individual plans for service provision, based on patient needs, utilizing a multi-disciplinary approach to achieve optimal health outcomes. In supporting the development of a robust coordinated care plan, the Care Coordinator (CC) may connect the patients to additional resources and supports in the broader system.

The purpose of this position is to assist patients in safely achieving their highest level of functioning and independence, consistent with their values, priorities, capacities and preference of care. Care Coordinators will collaborate with patients, hospitals, primary care providers, service provider organizations, and community support service organizations to plan and deliver care and ensure patients are connected to other supports. In accordance with the Connecting Care Act, 2019 and its regulations, the Care Coordinator assesses patient needs, determines eligibility for services, plans and implements care, helps coordinate service delivery with an inter-disciplinary team, and reviews patients’ care plans as required to ensure needs are being met to achieve their goals of care.

Care Coordinators report to a OHaH Patient Services Manager for employment-related matters and are accountable to the Leading Project OHT for advancing integrated, team-based care.

Care Coordinators will work as part of an integrated care team with OHT partners to carry out care coordination functions. As an integral member of the integrated care team, the Care Coordinator will contribute to the testing of home care models that improve integration, access, and patient outcomes and experience. Through the LP, the CC will contribute to building OHT and health system capacity for home care planning, delivery, and integration.

Mississauga OHT Leading Project Details:

In addition to Care Coordination duties outlined in the Care Coordinator job description, the role may include, but not be limited to the following:

• Assess the health status of the patient, including but not limited to ESAS and PPS.
• Initiate Goals of Care discussions and End of Life planning.
• Educate on “What to expect with regards to Palliative Care and EOL” including palliative resources available.
• Provide Pain and Symptom Management by being familiar with contents of Symptom Management Kit and other prescribed medications.
• Administer other medications as prescribed via prescribed route.
• Educate patient and family re: use of narcotic medication and other medications.
• Initiate and monitor CAAD PCA Pump.
• Complete a medication reconciliation (MedRec).
• Administer IV hydration as per medical orders including IV start if required.
• Educate & support patient and family with new IV/ injectable meds & assess ongoing needs.
• Complete Do Not Resuscitate (DNR) and Planned Death At Home (PDAH) form as appropriate.
• Provide emotional and psycho-social support to patient and family/caregivers.
• Consult with MRP and Palliative care Nurse Practitioner as required.
• Provide patient care as per patient’s care plan.
• Provide support to patient/family for Medical Assistance in Dying (MAID) provision as required.
• Report any changes in health status to the MRP and Home and Community Care Support Services Palliative Care Coordinator.
• Perform any additional tasks that are within the CNO (RN) scope of practice guidelines according to your skills, knowledge and judgement to perform.
• Potential for shift nursing on weekends if available.

Please note: Pending the go-live launch date of the Leading Project, the incumbent will work within the existing Palliative Care Coordination team model until the launch of the Leading Project.

What will you do?

Care Coordinators will be responsible for:

• Assessing - and reassessing when appropriate - patient requirements, including through mandatory interRAI assessments.
• Making determinations of eligibility.
• Developing care plans, and evaluating and revising them as necessary when the patient’s requirements change.
• Terminating the provision of a service.

Care coordinators will also be responsible for working with staff of HSPs and SPOs, who may also be responsible for:

• Revising care plans based on clinical expertise, within the context of the approved model of care.
• Carrying out additional clinical assessments to inform care planning.
• Assessing/reassessing patient needs for other health and social services.
• Providing information about - and referrals to - providers of other health and social services.

Care coordinator responsibilities will also include:

Identification and Engagement

• Engage and develop meaningful partnerships with health system partners involved in the patient’s care.
• Respond to inquiries and requests for service in accordance with the patient’s care needs.
• Provide the patient with information about legislation, OHaH, LP OHT, Patient Bill of Rights and responsibilities under the Connecting Care Act, 2019, and services available.
• Problem-solve inquiries and issues with the patient’s care plan execution and service providers.
• Respect the patient’s privacy, autonomy, ethnic, spiritual, linguistic, familial and cultural differences.
• Obtain consent for the gathering and sharing of patient information.
• Apply a health equity lens with a goal to address the root causes of health inequities.

Patient Needs Assessments

• Facilitate needs assessment information exchange across providers.
• Determine capacity and assess for placement into long term care facilities as required.

Accessing Resources and Linking

• Provide system navigation services and referral to appropriate community organizations.
• Engage the patient & family and relevant health and social services stakeholders.
• Plan for patient transition from hospital to community as required.

Clinical Care

• Provide direct care responsibilities as defined by the scope of the Leading Project.

Community Relations

• Foster and sustain effective relationships with a broad group of system partners.
• Engage with Health Care team members to build awareness of care coordination practice.

Care Planning and Coordination

• Monitor the coordinated delivery of services set out in the patient’s care plan.
• Establish care goals in the care plan in collaboration with the patient.
• Ensure strategies and actions outlined in the care plan are initiated and reviewed at all transition points.

Monitoring and Reassessment

• Monitor the outcome of the plan to ensure identified issues are escalated appropriately.
• Reassess for ongoing eligibility and continuing needs for service.

Resource Management and Fiscal Accountability

• Authorize home and community care service delivery in accordance with the care plan.

Evaluation

• Evaluate patient satisfaction with services.
• Contribute to data gathering for evaluation of Leading Project.

Documentation

• Maintain patient documentation in accordance with professional documentation standards.
• Document appropriately and as required in partner electronic health records.

Other Related Tasks:

• Work respectfully, positively and collaboratively within a team environment.
• Collaborate with team members regarding coverage for patient care.
• Promote Best Practice and helps define best practices.

Patient Safety:

• Promote patient safety in alignment with the Vision, Mission, Values and Strategic Directions of OHaH and the Leading Project OHTs.

What must you have?

• Membership, in good standing, with the applicable regulatory body:

• College of Nurses of Ontario
• College of Physiotherapists of Ontario
• College of Occupational Therapists of Ontario
• Ontario College of Social Workers and Social Service Workers
• College of Audiologists and Speech Language Pathologists of Ontario

• Minimum two years recent experience in community health or a related field.

Clinical Skills

• Working knowledge of the nursing and palliative process.

Administrative and General Skills and Attributes

• Knowledge of and adherence to identified OHaH and LP OHT policies.
• Solid ability to use MS Office applications and internet research skills.
• Strong understanding and commitment to quality service and best practice.

Communication & Interpersonal Skills

• Strong written and verbal communication skills.
• Empathy to sensitive issues.
• Ability to communicate in French or another language an asset.

What would give you the edge?

• Experience working with diverse patient groups.

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.
• Valuable development opportunities.
• Membership in a world class defined benefit pension plan.

Who we are

We are Ontario Health atHome, ready to serve every person in Ontario.We partner with patients and caregivers, primary care providers, 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 welcome and encourage applications from all qualified applicants.

We thank all applicants for their interest; however, only those selected for an interview will be contacted.