Bilingual Float Care Coordinator, Regular Full-Time, Eastern Labelle

Job Description
CARE AND BE CARED FOR – THIS IS YOUR HOME

Are you an experienced registered nurse, physiotherapist, occupational therapist, social worker (MSW), 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 Float Care Coordinator
, you will assess and determine patient care needs and eligibility, provide accessand 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-centered 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 andwork-life balance.

What will you do?

Under the general direction of the Manager, Ontario Health atHome and in accordance with the Ontario Health atHome Champlain standards, legislation, policies and guidelines, the Care Coordinator is responsible for client assessment, determination of eligibility, admission, service planning and authorization, implementation, monitoring, reassessment, adjustment and discharge planning of all client service programs (home care and placement), including the provision of community resource information and referral.

As a member of the 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.

Care Coordinator will work collaboratively with patients, families, caregivers, and hospital partners to develop a care plan to support a safe transfer from hospital to home for both complex and non-complex patients. Care Coordinators must prioritize work based on the ever changing needs of patients and hospital environment while meeting the Ontario Health atHome Champlain Guidelines of Care. The Care Coordinator will participate in various meetings to support care planning and communication with partners within the circle of care, including family meetings, care conferences, bullet rounds, and joint discharge rounds.

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
• Identification and Engagement – Assesses referred clients for…