Reporting to the Manager of Patient Care, Care Coordinators are responsible for assessing, planning, coordinating, implementing and reviewing patient's care needs and services provided by the LHIN following Ministry of Health legislation and HNHB LHIN policies and procedures. Care Coordinators are also responsible for providing information and/or referring patients to alternative community resources.
There are two functional areas within Care Coordination: Community and Access. Within the Community Care Coordination are specialty teams to address some of the unique service needs in our service area. Access refers to the Intake Care Coordination functions performed through our hospitals, community intake and after hours Care Coordinators.
Next Projected Hiring Date: September 14, 2020 with 4-6 weeks' Full Time paid orientation to start (required).
Core Duties - Responsibilities:
Identification and Engagement:
To respond to inquiries and requests for service in accordance with the patient's care needs, identified risk factors, and urgency for services;
To provide the patient with information about legislation, Local Health Integration Network, client rights and responsibilities, and services available.
To problem-solve inquires and issues with the patient's needs and service provider’s need.
To obtain consent for the gathering and sharing of patient information.
To determine eligibility and assess for Local Health Integration Network services;
To determine capability and assess for placement into long term care facilities;
To counsel patient and family regarding the placement process; to understand the crisis component of urgent placement needs;
To plan for discharge;
To respect the patient's privacy, autonomy, ethnic, spiritual, linguistic, familial and cultural differences.
Promotes client safety in alignment with the Vision, Mission, Values and Strategic Directions of the HNHB LHIN.
Works within the basic principles of client safety by doing the right thing for the right client, using the right method at the right time.
Adheres to HNHB LHIN's client safety policies and procedures.
Accessing Resources and Linking:
To assist patients to access alternative community resources by providing appropriate information and referral.
To develop a service plan that reflects the patient's assessed needs.
To establish goals in collaboration with the patient to ensure goals reflect the patient's desired outcomes, within the resource parameters of the Local Health Integration Network.
Service Implementation and Coordination:
To implement a coordinated service plan that reflects the patient's needs and goals for service.
Monitoring and Reassessment:
To monitor progress towards established goal;
To reassess referral to appropriate team;
To reassess for ongoing eligibility and continuing needs for service; to discharge services when appropriate;
To link patient to other community services.
To authorize the appropriate LHIN services to ensure the effective and efficient utilization of resources.
To order, allocate, and authorize services and manage expenditures within the Service Planning and Ordering Guidelines (units of service);
To negotiate visits frequency with patient and service providers and problem solve discrepancies regarding billing with service providers.
To evaluate patient satisfaction with services, and to identify opportunities to improve the delivery of Local Health Integration Network services;
To identify trends that will impact LHIN resources;
To complete service feedback forms.
To maintain professional and LHIN documentation in accordance with professional documentation standards including the completion of appropriate forms;
To maintain accurate electronic client files.
To interpret the Local Health Integration Network services to patients, families, community groups, and other health/social services providers through presentations and panel participation;
To develop partnerships with others in the community.
Other Related Tasks:
Collaborates with team members regarding work flow coverage
Precepts and mentors staff. Acts as a resource to other staff to assist in orientation, implementing change, and problem solving.
Assists with projects and new initiatives as they relate to position.
Participates on committees.
Promotes Best Practices and helps define best practices.
Promotes and supports research initiatives.
Participates in relevant educational opportunities.
Other duties as assigned.
A University Degree. An equivalent of education and experience may be considered. Registered Nurses with a Diploma in Nursing shall receive equal consideration.
Practitioner in one of the following health disciplines: nursing, physiotherapy, occupational therapy, medical social work, dietetics, or speech-language pathology
Maintain membership in a Regulated Health Professional College
Minimum two years' recent experience in community health or a related field
Knowledge of community resources
Experience in acute care setting an asset for Access and Acute Teams
Experience related to paediatrics is an asset for the Paediatric/School Team
Experience related to palliative care and palliative care courses is an asset for the Palliative Team
Skills & Abilities:
Problem-solving and decision making skills
Interpersonal communication skills (written and verbal)
Accessing community resources
Ability to work independently as well as in a team setting
Collaboration with Internal and External stakeholders
Organization, goal setting, planning, coordination and evaluation skills
Computer experience and keyboarding skills on a lap top and desk top computers
Flexibility during transition
Valid driver’s license
Access to a motor vehicle
Driving to and from patient visits specific to community teams
A satisfactory Criminal Record Check with Vulnerable Sector Search will be required for employment.
A facility in other languages is an asset.
HOURS OF WORK:
Standard hours of work: Monday to Friday, 8:30 am – 4:30 pm within the main office and hospital sites.
Other available shifts: Sunday - Saturday, 10:00am – 6:00pm and 1:00pm – 9:00pm within the hospital and intake teams.
In order to maintain your employment status as a Part Time B Care Coordinator, you must provide the following availability:
(a) 44 (forty-four) weeks of the year including the month of December and either
the month July or August.
(b) Available 1 (one) weekend and 1 (one) weekend day (Saturday or Sunday or paid
holiday) per calendar month.
(c) Available six (6)- seven (7) hour shifts, four (4) - ten (10) hour shifts, or five (5)
shifts in combination per bi-weekly period including the weekends and extended
hour commitments, and of which at least one (1) shift will be a Friday. Shifts
must be applicable to the employees’ home branch.
(d) Available for at least five (5) paid holidays in each fiscal pay year, including either
Christmas Day or New Year’s Day. Christmas Day and New Year’s Day availability
will be rotated on a yearly basis.
(e) No more than fifty percent (50%) of PT B employees in a branch may make
themselves unavailable in any one month. If there is a conflict in the nonavailability
indicated by employees, the conflict will be resolved on the basis of
applying the following:
i. Alternating July and August each year and on a rotational basis for other
ii. Seniority where (i) does not resolve the conflict.
(f) If a PT B employee is unavailable for a period of one week or more, the employee
must submit information to the Employer within the time frame of the vacation
request process as outlined in Article 16 - Vacation.
All other availability must be submitted on the first (1st) day of the month for the following month. For July and August, Availability Templates must be submitted by May 1st. After the schedule has been posted, the PTB employee will have no obligations to availability except as scheduled.