Palliative Clinical Care Coordinator

Job Description

Are you an experienced registered nurse (BScN), looking for a different kind of practice environment? You’re looking in the right place.

This position is responsible for collaborating with patients and their families 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 Clinical Care Coordinator (CLCC) 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. Clinical 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 Clinical Care Coordinator assesses patient needs, determines eligibility for services, plans and implements care, helps coordinate service delivery with an interdisciplinary team, and reviews patients’ care plans as required to ensure needs are being met to achieve their goals of care. Clinical Care Coordinators will also carry out their duties in accordance with OHaH policies and the Leading Project OHT’s policies, procedures and parameters relating to the delivery of Clinical Care Coordination functions including mandatory points of consultation, communication and collaboration with the other members of the integrated care team.

Clinical 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.

With shared accountability between OHaH and the OHT, with clearly defined models of home care planning, policies, service allocation and delivery informing accountability, roles and responsibilities, Care Coordinators connected with an Ontario Health Team Leading Project 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. Leveraging the key activities of care coordination, the OHT LP CLCC will help to inform potential scale and spread of new models of home care, including system processes and supports. Through the LP, the CLCC will contribute to building OHT and health system capacity for home care planning, delivery, and integration.

What will you do?

• The CK OHT Leading Project has the following objectives:
  • Improve coordinated and seamless care delivery for individuals with any life-limiting diagnosis who would benefit from a palliative approach to care;
  • Improve patient and caregiver experience throughout the entire patient’s palliative care trajectory;
  • Implement an integrated model of palliative care connected to hospice with Palliative Clinical Care Coordinators as the single point of contact and are embedded in primary care;
  • Provide patients and their families with timely, equitable access to high-quality care, close to home in an expanded, patient-centred approach that supports home care modernization through innovation and utilizing the strengths of current digital platforms (ie CHRIS) to enhance care delivery;
  • Support broader integration and coordination of health care resources; optimizing use of current HHR; and leverage and expand upon best practice;
  • Improve coordination and communication of care for palliative patients by establishing direct communication pathways between the PCCC and the most responsible provider or primary care provider resulting in improved patient care;
  • Develop clear clinical pathways based on goals of care discussion with frequent reassessment to ensure the appropriate supports are in place at the appropriate time of the care journey. This includes a standardized process for communication with Palliative Care team, which includes the primary care provider to ensure patient and caregiver needs are being met;
  • Advance and evaluate the project using the lens of the Quintuple Aim.

What must you have?

• Membership, in good standing, with the applicable regulatory body: College of Nurses of Ontario (RN, BScN)
• Appropriate university degree or a suitable combination of education and direct experience;
• Field of registration must allow applicant to determine patient capacity in accordance with the Health Care Consent Act (1996)
• 1-3 years of experience in community health or a related field;
• Basic knowledge of and adherence to relevant legislation and regulations, including the Home and Community Care Services Regulation of the Connecting Care Act, 2019 and Personal Health Information Protection Act (PHIPA);
• Basic understanding of issues and priorities within the healthcare sector;
• Good knowledge of Home Care patient services strategies, objective, priorities;
• Knowledge of direct care/case management models used in community health care organizations to support system navigation and hospital avoidance.
• Working knowledge of the nursing process, the consultation process, program planning and crisis management;
• Superior clinical assessment skills;
• Knowledge of and adherence to identified OHaH and LP OHT policies, procedures and related practices;
• Solid ability to use MS Office applications (e.g. Word, Excel, Outlook, PowerPoint, etc.) and internet research skills and computer navigation is required;
• Strong understanding and commitment to quality service and best practice;
• Ability to analyze information, problem-solve and make good decisions;
• Accountable for own actions and decisions, making decisions within the scope of the position and referring issues/problems/events to the Patient Services Manager for employment related matters and referring issues related to the integrated care model to the OHT lead as required;
• Solid documentation skills (clear, thorough, accurate and timely);
• Self-directed with the ability to organize, prioritize and multi-task;
• Flexible, adaptable and responsive to change;
• Detail-oriented.
• Strong written and verbal communication skills;
• Courteous and respectful in all interactions;
• Understanding of and ability to practice culturally safe and trauma-informed care, particularly when serving Indigenous clients and families;
• Ability to establish and maintain a wide range of contacts with professionals and organizations within the community;
• Solid effective listening and facilitation skills;
• Ability to maintain confidential information;
• Empathy to sensitive issues;
• A valid driver’s licence and access to a reliable vehicle;
• 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?

• Experience working with diverse patient groups, e.g., multicultural, homeless, palliative, acquired brain injury (ABI), mental health, geriatrics, pediatrics
• Case management experience or recent related community experience
• Ability to speak French or another second language

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
• Salary: $40.23/hr to $52.80/hr

What do I need to know?

Anticipated Start Date: May 26, 2025

Status: Full-Time - Hours of work: Monday to Friday – 830am-430pm or 8:00am-4:00pm

Site: Windsor site

Posting Expiry: April 30, 2025

Unionized Position – Embedded in primary care (Chatham Kent Family Health Team or Chatham Kent Community Health Center) the Palliative Care Clinical Care Coordinator will attend hospital and hospice to support patient transitions as needed. Periodic travel throughout the Erie St. Clair region may be required.

Who we are

We are Ontario Health at Home, 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 at Home 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.