Care Coordinator, Temporary Full Time, Health Links, Cornwall

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Position ID:
Job Title:
Care Coordinator, Temporary Full Time, Health Links, Cornwall
Job Location:
Cornwall, Ontario, Canada
Posting Date:
November 7, 2019
Posting Expiry Date:
December 13, 2019
Language Requirement:
Reporting Manager Title:
Manager, Home and Community Care

The Champlain Local Health Integration Network’s (LHIN) mandate is to ensure health services are well-organized, appropriately funded, and meet the health needs of the 1.3 million residents who call this region home.

We work with and fund roughly 120 health service providers that offer about 240 health programs in hospitals, community support services, mental health and addiction services, community health centres, and long-term care homes. The Champlain LHIN also delivers home and community care services.

Position Summary:

There are currently five Health Link networks in the Champlain region. Through partnerships with organizations such as community hospitals, addictions and mental health agencies, primary health care service providers, community support services and social service agencies, these Health Links work to improve health outcomes for people with complex health conditions. The Health Link networks are committed to increasing the level of, and access to, primary health services through an integrated team of health care professionals emphasizing health promotion, disease prevention and improved management of chronic disease.

As a key member of the Champlain LHIN Health Link team, the Care Coordinator – Health Links will utilize an intensive case management approach, bringing all members of the care team together, including the patient and their family/supports, to develop and support the implementation of a coordinated care plan based on the priorities and activities that have been identified by the patient. Through multiple consultations and visits, the Care Coordinator – Health Links aims to improve the patient experience by working with the patient and their family to creatively problem solve issues, and health and social service partners to build a plan of care for the patient which will in turn reduce their use of the emergency department and hospitalization.

Primary Responsibilities:

Managing a caseload of complex needs patients, and in collaboration with relevant primary health care providers and specialists, acute care settings, community agencies and programs and with social service partners (housing, transportation, etc.) the Care Coordinator - Health Links will:

• Collaborate with the community Champlain LHIN Care Coordinator to enroll Champlain LHIN patients identified as meeting the Health Links criteria and ensure a smooth transition to the Care Coordinator – Health Links
• Play a key role in improving patient transitions within the health care system by encouraging a high level of collaboration and co-ordination between members of the patient’s care team. This will be especially key during hospital to home/community transitions.
• Facilitate the development of a personalized patient-driven coordinated care plan that is reflective of the patient and family’s goals, using a standardized coordinated care plan template and approach.
• Ensure common understanding and participation by the patient and care team towards the achievement of the patient’s goals within the defined timeframes and criteria
• Conduct as needed touch-points with Health Links patients to encourage self-management, gauge progress, provide support and real time care plan adjustments as needed
• Ensure the implementation of the coordinated care plan amongst all care team partners and the patient and proactively identify and remove barriers that may inhibit the patient from achieving their goals
• Assist patients in receiving responsive care that addresses their specific needs with the support of a tightly knit team of providers Leverage partners from across the health, social and community sectors to bridge services to address gaps for patients
• Act as a trusted resource and provide coaching/teaching to patients and their families/supports in various areas that may include chronic disease self-management, coping skills, effective communication and other soft skills
• Advocate on behalf of patients when required to ensure their voice is heard which may include accompaniment to appointments when requested/required
• Monitor through regular assessment and adjust the care plan based on changes in the patient’s needs, goals and strengths
• Participate as a member of the Health Links Community of Practice to build inter-linked relationships and to learn and develop improved practices

Education and Experience:

Academic Qualifications and Experience:
• Registered Nurse (BScN or diploma) with a current Certificate of Registration from the College of Nurses of Ontario; or
• Degree or diploma in Physiotherapy and registered with the College of Physiotherapy of Ontario; or
• Degree or diploma in Occupational Therapy and registered with the College of Occupational Therapy of Ontario; or
• Degree in Social Work and registered with the Ontario College of Social Workers and Social Service Workers.

• Experience working in a community care setting that includes client counseling, case management and discharge planning which is normally attained over a period of two years
• A minimum of four (4) years’ experience in a community care setting that includes client counseling, case management and discharge planning
• Experience working with, collaborating and linking with other community health and social service agencies
• Experience working in the area of intensive case management with complex clients is an asset
• Mental Health education and experience is an asset


Subject Matter Knowledge:
• Knowledge and understanding of the broader health care delivery system and available resources within the Champlain region
• Solid knowledge of the determinants of health and how they impact on population health and that of marginalized populations

Champlain LHIN Knowledge:
• Knowledge of Champlain LHIN operations, quality, risk, and performance management principles
• Knowledge of relevant health care legislation
• Knowledge of Champlain LHIN policies, procedures, strategic direction and goals
• Understanding of Champlain LHIN partners and contracted service providers in the community

• Ability to accurately complete required documentation, reports, and forms
• Working knowledge of computer software (email, internet) and Microsoft Office applications (Word, Excel, Power Point, etc.)

Skills and Abilities:

• Builds a highly effective therapeutic relationship with patients and families by building trust and gaining credibility
• Manages difficult conversations/situations with patients, families, physicians, nurses and other interdisciplinary team members in a constructive, compassionate, non-judgmental, effective and diplomatic manner
• Works effectively both independently and as part of an inter-disciplinary team
• Establishes and maintains a wide range of partners from the health, social and community sectors within the Health Link network and uses effective verbal and written communication with the partners
• Listening and facilitation skills to work with patients and their families and partners
• Supportive approach in motivating and empowering patients to be active members of their care planning while increasing independence
• Relationship building within the Health Link network (and beyond as required) to facilitate social and personal supports, such as arranging housing, linking with food banks, finding someone to help with taxes, friendly visiting, etc.
• Time management and prioritization of tasks, as well as flexibility in adjusting to priorities in a dynamic environment
• A valid driver’s license and access to a vehicle is required
• Vulnerable Sector Check completed within the last six months

Affiliation: Wages are in accordance with the collective agreement between Champlain LHIN and OPSEU and starting salaries range from $38.16/hr. - $40.77/hr.
Shift: Monday to Friday, 8:30am to 4:30pm
Location: Cornwall

This position is temporary until approximately September, 2020.

All applications will be reviewed; however, only those selected for an interview will be contacted.

Champlain LHIN welcomes and encourages applications from people with disabilities. Accommodations are available on request for candidates taking part in any aspects of the selection process.